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1

Maslow's Hierarchy of Needs

(basic to complex)

-Physiologic (food, shelter, water, sleep, oxygen, sexual expression)

-Safety

-Love and Belonging

-Esteem and Recognition

-Self-Actualization

2

Nursing Process

ADPIE

Assessment
Diagnosis (Analysis)
Plan
Implementation
Evaluation

3

Nurse Practice Act

-Provides laws that control and regulate the nursing practice in each state to protect public from harm. They vary from state to state.
-Govern the nurse's responsibility in making assignments.

4

Tort

An act of involving injury or damage to another resulting in civil liability (i.e. victim can sue) instead of criminal liability.

5

Negligence

-Form of unintentional Tort
-Performing an act that a reasonable and prudent person would not perform

6

Malpractice

-Form of unintentional Tort
-Negligence by professional personnel that RESULTS IN INJURY

4 elements necessary:
Duty: obligation to use due care
Breach of Duty: failure to perform according to standard
Injury/Damages: failure to meet standard of care resulting in physical or mental injury or damage to client
Causation: A connection exists between conduct and resulting injury

7

Intentional Torts

-Assault (mental or physical threat)
-Battery (actual and intentional touching)
-Invasion of privacy (false imprisonment, exposure of a patient, defamation)
-Fraud

8

Surgical Permit

Written
Voluntary
Informed (explained to the client)

9

Informed Consent

-Possible complications, risks, disfigurements
-Removal of any organs or parts of the body
-Benefits and expected results

10

Consent for minors

Children 14-years-old must agree to procedure along with parent/guardian

11

HIPAA

Health Insurance Portability and Accountability Act of 1996
-patient privacy
-non-compliance can result in civil and criminal liability

12

Good Samaritan Act

Protects nurse when providing emergency care

13

LEADERSHIP STYLES

Democratic
Authoritarian
Laissez-faire

Democratic (parcipative): Assertive

Authoritarian (autocratic): Aggressive

Laissez-faire (permissive): Passive

14

5 Rights of Delegation

Right:
Task
Circumstance
Person
Direction/Communication
Supervision

15

Lewin's Change Theory

(Nurse Leaders/Managers as Change Agents)

Unfreezing- Initiation of a change
Moving- Motivation towards a change
Refreezing- Implementation of a change

16

4 Core Competencies for Interprofessional Collaborative Practice

1. values/ethics for interprofessional practice
2. roles/responsibilities
3. interprofessional communication
4. teams and teamwork

17

Ebola

-Risk in US low ,even when working in West African communities.
-Direct contact with blood or bodily fluids
-Contagious after symptoms start (fever, severe headache, muscle pain, diarrhea, vomit, unexplained bleeding).
-21 day isolation
-Full PPE

18

Zika Virus

-Microcehpaly in babies of mothers with Zika
-Remains in blood of infected person for 1 week

19

Disaster Biologic/Chemical/Radiation Agents

Biologic agents:
Anthrax, Pneumonic Plague, Botulism, Smallpox, Inhalation tularemia, Viral hemorrhagic fever

Chemical agents:
Biotoxin agents (ricin)
Nerve agents (sarin)

Radiation

20

Acute Respiratory Distress Syndrome
(ARDS)

-Unexpected, catastrophic pulmonary complication occurring in a person with no previous pulmonary problems. Morality rate ~50% (higher with hx or etoh).
-Characterized by hypoxemia (even on 100% oxygenation), decreased pulmonary compliance, dyspnea, non-cardiac-associated bilateral pulmonary edema, dense pulmonary infiltrates on radiography

-Interventions: Elevate HOB 30 degrees, assist with daily awakening, implement comprehensive oral hygiene program, implement a comprehensive mobilization program.

21

What PaO2 value indicates respiratory failure in adults?

PaO2 <60 mm Hg

22

What blood value indicates hypercapnia?

PCO2 >45 mm Hg

23

Respiratory failure symptoms

-Dyspnea, hyperpnea, crackles (rales), wheezing, decreased breath sounds
-intercostal or substernal retractions
-cyanosis, pallor, molted skin
-increasing diminished breath sounds
-diffuse pulmonary infiltrates on chest radiography (white-out appearance)
-verbalized anxiety, restlessness, confusion, agitation

24

Shock

-Widespread, serious reduction of tissue perfusion (lack of O2 and nutrients)
-Early signs= agitation and restlessness from cerebral hypoxia

Types: Hypovolemic (most common, early/severe below), Cardiogenic, Distributive, Obstructive.

EARLY: tachycardia, hypotension, weak periph pulses, restlessness/agitation/confusion, pale cool clammy skin, decreased urine output (<30 mL/hr)

SEVERE: organ dysfunction, renal failure, pleural effusion, resp distress... renal failure and/or death.

25

Disseminated Intravascular Coagulation (DIC)

In disseminated intravascular coagulation, abnormal clumps of thickened blood (clots) form inside blood vessels. These abnormal clots use up the blood's clotting factors, which can lead to massive bleeding in other places.

Prolonged PT, PTT
Decreased platelets
Increased FSPs

Obvious signs of bleeding, such as hematuria, hematoma at venipuncture sites, hemorrhage in conjunctiva, petichiae.

Treatment: Heparin

26

HELLP Syndrome

(hemolysis, elevated liver enzymes, low platelet count)

-Usually develops before the 37th week of pregnancy but can occur shortly after delivery. Many women are diagnosed with preeclampsia beforehand.

Symptom Triad:
Headache
Nausea/Vomit
URQ/Abd pain (distended liver)

-Treatment usually requires delivery of the baby, even if the baby is premature.

27

Resuscitation (emergency)

Adults /Children: CAB
Chest compressions, airway, breathing)

Newborns : ABC
Airway, breathing, chest compressions

100 compressions/min
2 in/5 cm deep

1 rescuer: 30:2 (for all)
2 rescuers: children/neonate 15:2

28

Cardiac arrest on bedside monitor?

Defibrillation

29

1st drug in hospital for cardiac arrest?

Epinephrine

Also for anaphylactic rxns and severe asthma

30

-Chocking child or infant procedure?
-"blind sweep" of mouth in children or infants?

-Child: subdiaphragmatic abdominal thrusts (Heimlich maneuver) until object expelled or pt unresponsive.
-Infant: repeat cycle of 5 back blows (slaps), 5 chest compressions until expelled or unresponsive.

-NEVER! The object might be pushed farther down into the throat. Only go in if object can be seen.

31

Fluid volume deficit

-H2O and electrolytes can be lost isotonically (serum levels would remain normal)
-Dehydration
-oliguria (concentrated urine), weight loss, postural hyptension, weak/rapid pulse, decreased skin turgor, dry mucous membranes
-Elevated BUN and creatinine, increased osmolarity, elevated Hgb/Hct

32

Fluid volume excess

-H2O and electrolytes can be retained isotonically
-Water intoxication; retain water and Na decreases
-HF, RF, Cirrhosis, excess NaCl ingestion, over-hydration with Na-containing fluid, poorly controlled IV therapy.
-Attention loss, confusion, aphasia, altered LOC
-Decreased BUN, Decreased Hgb/Hct, Decresed serum osmolality, Decreased urine osmolality and specific gravity
-JVD and peripheral edema

33

BUN

Blood urea nitrogen is a medical test that measures the amount of urea nitrogen found in blood. The liver produces urea in the urea cycle as a waste product of the digestion of protein.
-Directly r/t metabolic function of the liver and excretory function of the kidneys

34

Creatinine

-Chemical waste product from muscle metabolism, which fluctuates very little.
-Kidney function (GFR)
-Affected very little by dehydration, malnutrition, or hepatic function... better test for renal function than BUN.

35

erythropoietin (EPO)

Hormone manufactured by kidneys.
-promotes the formation of red blood cells by the bone marrow.
-damaged kidney= less EPO=reduced oxygen

36

Standard precautions

-Wash hands, even if gloves have been worn
-Wear gloves for touching blood or bodily fluids or any non-intact body surface
-Wear gowns during any procedure that may produce splashes (ex. change client with diarrhea)
-Masks and eye protection during any activity that might disperse droplets (suctioning)
-Do not recap needles, dispose in puncture-resistant container
-Use mouthpiece for resuscitation efforts

37

CD4 T-cell count r/t HIV

CD4 T-cell count:
describes # of infection-fighting lymphocytes a person has

HIV infection destroys CD4 T-cells ad invades them and replicates

38

HIV

transmission: blood and bodily fluids (unprotected sex, sharing needles, infected blood products, breast milk, needle stick)

Universal precaution: protection from blood and bodily fluids is the goal. Initiate barrier protection b/w caregiver and client (hand washing, gloves, gowns/masks, eye protection)

Labs: Confirm with Western blot test
ELISA can have false-positives

39

PQRSTU

PAIN

Provokes (what makes it worse/better?)

Quality (dull, aching, sharp, stabbing, burning)

Region (where and does it radiate anywhere?)

Severity (pain scale)

Timing (how long, how often, and when?)

Understanding (what do they think causing pain)

40

5 stages of grief

Denial
Anger
Bargaining
Depression
Acceptance

41

Ginger

Treatment of nausea

42

Garlic

decreases hyperlipidemia

Also anti-platelet. Stop taking before surgery

43

Ginseng

erectile dysfunction, reduce fatigue, enhance mental performance

44

St. John's Wort

Treats depression

Do not mix with other antidepressants (SSRI's and tricyclic antidepressants)

45

Hydration

-thins out mucus trapped in bronchioles and alveoli- facilitates exporation
-essential for client experiencing a fever
- 300-400 mL fluid lost in lungs daily through exporation

46

Increased temps cause...

increase in metabolism and demand for oxygen. Fever also causes dehydration because of excess fluid loss (diaphoresis)

47

Blue bloater

Chronic bronchitis

Use of accessory muscles to breath
Leads to RSHF (cor pulmonale)
Bilateral pedal edema
JVD

48

Pink puffer

Pulmonary emphysema

"floppy" alveoli
increased CO2 retention (pink)
pursed lip breathing (prolonged expiration)
barrel chest from chest overinflation
unproductive cough
tripod position
hyper-resonance upon lung auscultation
thin in appearance
leads to RSHF (cor pulmonale)

49

COPD

Chronic Obstructive Pulmonary Disease

Chronic bronchitis (blue bloater) and pulmonary emphysema (pink puffer)

Exposure to tobacco is #1 cause in US

-Report S/S infection (fever, increased sputum, worsening dyspnea)
-Get Flu and pneumococcal vaccine
-Use albuterol, ipratropium if SOB emergency
-eat frequent, small, high calorie meals because of increased energy/work for breathing
--too full puts pressure on diaphragm

-May lead to polycythemia (increase RBCs). Body trying to compensate for chronic hypoxia.

50

ABC vs CAB

ABC-prioritize nursing actions

CAB- during CPR

51

Tuberculosis Dx and Meds

TB test (mantoux) 10mm or greater in diameter 48-72 hrs after test

If (+) and Asymptomatic-might be latent (cannot transmit). Will have normal CXR and neg sputum culture.

Meds: RIPE
*Rifampin/Rifapentine
-Red/orange discoloration of body fluids/tissues
---could perm discolor dentures and contact lenses
-Reduces effectiveness of contraceptives
-Take with meals
-Hepatotoxicity (have liver function test each month)
*Isoniazid
*Pyrazinamide
*Ethambutol

52

Intracellular and Extracellular ions

Intracellular: Potassium and Phosphate

Extracellular: Sodium and Chloride

53

uremia

a raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys.

Protein should be restricted in CRF clients

GFR used as protein consumption indicator

54

Acute vs Chronic Renal Failure

Acute: often reversible, abrupt deterioration of kidney function

Chronic: irreversible, slow deterioration of kidney function AEB increased BUN and creatinine. Dialysis eventually required

55

Acute Renal Failure Types and Phases

Phases:
*Oliguric- Decreased Output! Pt in FVE, K increases because not excreting urine=HYPERKALEMIC
*Diuretic- Increased Output! Pf in FVD (potential shock), excreting a lot of K=HYPOKALMIC
Recovery-

Types:
*Prerenal- interference with renal perfusion
*Intrarenal- damage to renal parenchyma
*Postrenal- obstruction in urinary tract from the tubules to the urethral meatus

56

Digoxin

Increases strength and contractility of the heart.
Increases CO
Increases Kidney perfusion
*Decreases HR (Hold if HR <60 bpm)
--Apical pulse for 60 seconds

Normal level: 0.5-2 ng/mL
Used in: a-fib (controls arrhythmia), CHF

Toxicity:
Early: anorexia, nausea, vomit
Late: arrhythmia and vision changes (halo of light or anything else)

57

Nitroglycerin

causes dilation of coronary arteries allowing more oxygen to heart muscle

used for chest pain (1 every 5 min for 15 min)

58

Atropine

increases heart rate by blocking vagal stimulation (suppresses HR)
Treats brady!

59

Myocardial infarction med admin

MONA
morphine, oxygen, nitroglycerin, aspirin

60

Abdominal Aortic Aneurism

-An enlargement of the aorta, the main blood vessel that delivers blood to the body, at the level of the abdomen.
-life-threatening if it bursts.
-common in older men and smokers.
-grows slowly, without symptoms.
-Progress: some people may notice a pulsating feeling near the navel. PAIN IN THE BACK, belly, or side may be signs of impending rupture.

61

Thrombophlebitis

A condition in which a blood clot in a vein causes inflammation and pain.

62

Sodium warfarin

Coumadin
Takes 48-72 hrs to take effect. Overlap with heparin common
PT (Prothrombin time) 10-12 sec
INR: 2-3
Antidote- Vitamin K

Uses:
A fib to prevent clots and reduce stroke risk, DVT, PE, Mechanical heart valves (prevent clots on valves)

Contraindicated in pregnancy

63

Heparin

aPTT 30-45 sec
Antidote- protamine sulfate

64

APGAR Score

Appearance
Pulses
Grimace
Activity
Reflex/Irritability

0=absent
1=decreased
2=strongly positive

7 and above= normal
4-6=fairly low
3 and below= critically low

65

Umbilical cord

AVA
2 arteries
1 vein

66

Maternal hypotension intervention

Stop pitocin
Turn on left side
Admin oxygen
If hypovolemia, push IV fluids

67

Antianemica

increase RCB production

68

Anticholinergic Side Effects

Hot as a Hare
Dry as a Bone
Blind as a Bat
Red as a Beet
Mad as a Hatter (confusion)

69

Antidiarrheals

Decreases gastric motility and reduce water in bowel

70

Miotics

Constrict pupils

71

Mydriatics

dilates pupils

72

Rule of nines

Body surface area for burns

Head: 9%
Arms: 18% (9% each)
Back: 18%
Legs: 36% (18% each)
Genitalia: 1%

73

Aluminum Hydroxide

Amphojel

GERD and kidney stones
Watch out for constipation

74

Hydroxyzine

Vistrail

Anxiety and itching
Watch out for dry mouth

75

Midazolam

Versed
Conscious sedation

Watch out for resp depression and hypotension

76

Dopamine

Treats symptomatic hypotension, shock, low cardiac output.
Monitor for arrhythmias and BP

77

CPR on pregnant woman

Chest compressions slightly higher on sternum

Displace uterus (might be crushing vena cava) by placing towels/wedge under right hip

78

Postpartum vaginal bleeding

Saturating 1 perineal pad <1 hr is excessive

boggy fundus= uterine atony, full bladder keeps uterus from contracting (make sure bladder empty)

Oxytocin- uterotonic if fundus massage fails

79

Diabetes Insipidus

decrease ADH made (or distributed from) hypothalamus

increase in thirst likely (polydipsia)

treatment: desmopressin acetate

80

Duchenne's MD

-frequent trips/falls at home
-places hands on thighs to push up to stand (Gower Sign/Maneuver)
-walks on tip toes and has disproportionately large calves
-progressive replacement of muscle tissue with connective tissue

81

glipizide

Type 2 diabetes treatment
oral sulfonylurea for blood sugar

82

levofloxacin

antibiotic
Other drugs/supplements canbind 98% of drug

Take 2 hrs post other meds/supps

83

Potassium chloride usually given with?

usually given with diuretic to prevent hypokalemia

84

heparin flush

usually 2-3 mL of 10 or 100 units/mL vials

85

Foods for Calcium, Vit D, and both

Calcium: cheese, ice cream, greens, almonds, soy, tofu

Vitamin D: tuna, oily fish, cod liver oil, egg yolks

BOTH: milk, yogurt, salmon, cereal

86

Suction Artificial Airway

-hyperoxygenate beforehand
-suction no more than 10-15 seconds
-wait at least 1-2 min between passes
-medium suction pressure for adults 100-120 mm Hg

87

Normal Troponins

Trop I <0.5
Trop T <0.1
increased for MI

88

Management of Cystic Fibrosis

Resp/Diet

Autosomal recessive
Thickened mucus and plugged ducts

RESPIRATORY:
-frequent respiratory/sinus infections
--blood-streaked sputum (hemoptysis) as result of damaged blood vessels common
--priority if pt has 90% O2 on RA
-Chest physiotherapy performed AFTER bronchodilators and nebs
-potential pneumothorax

DIET:
-pancreatic deficiency leads to decreased absorption of fat-soluble vits (ADEK)
-pancreatic enzymes on ALL food (burning if touches lips, make sure on food)
-need INCREASED CALORIC DIET (high protein)
--difficulty maintaining weight and growth
-fecal retention common..may have steatorrhea (fatty and frothy)

MISC:
-infertility

89

Scopolamine

-anticholinergic to prevent nausea/vomit with motion sickness
-behind ear (dry, hairless)
-4 hours before travel
-replace 72 hrs

90

Depression med directions

DO NOT combine use of SSRI (-pram) with MAOI (-ine).
-Risk of seratonin syndrome
-do not start SSRI until 14 days after stopping MAOI

91

INR

2-3
Risk of bleeding increases as INR rises.
If INR high, DO NOT ADMINISTER ANTICOAGULANT (warfarin)

92

Ventricular Tach on monitor
1st action?

CHECK PULSE
VT with and without pulse possible.

With Pulse: check for clinical stability and O2 sat
Stable? antiarrythmic meds
Unstable (AMS, shock, hypotension, CP, acute HF)? synchronized cardioversion

Without Pulse: CPR/Defib

93

Oxytocin Infusion

-Assess uterine contraction pattern
-Monitor I and O
-Place IV oxytocin in electronic infusion pump
-Connect to secondary line that's attached to the mainline in the PROXIMAL port. Prevents bolus and allows for sudden stop of infusion.
-Continuous electronic FHR monitoring

94

Post-op Chest Tube

Alert HCP if drainage:
>3mL/kg/hr for 3 consecutive hrs
OR
>5-10 mL/kg for 1 hr

Potential hemorrhage or cardiac tamponade

95

Hypothermia post op?

Normal

96

Infant I and O

1-2 mL/kg/hr

97

isosorbide

-Actions identical to nitroglycerine
-decreases cardiac workload by reducing preload and afterload
-Can cause hypotension from vasodilation
-Hold when systolic BP <90
(kidneys trouble with profusion at 80 mmHg)

98

Basal Long-Acting Insulin

Glargine (Lantus)
Detemir

Once Daily
Works up to 24 hrs
Onset: 1-1.5 hrs

99

Intermediate-Acting Insulin

NPH (Humulin N/Novolin N)

CLOUDY (draw clear before cloudy)
2x daily
Onset: 1.5-4 hrs

100

Short-Acting Insulin

Regular (R) Insulin
***Best for IV (DKA)

Onset: 30min-1 hr
Peak: 2-4 hrs
Duration: 8 hrs

101

Rapid-Acting Insulin

Lispro, Aspart, Glulisine
***Best for post-meal hyperglycemia


Onset: <15 min
Peak: 1-2 hrs
Duration: 4-6 hrs

102

Burns

Burn injuries cause cellular destruction, capillary leaking, and fluid shifts (emergent phase 24-72 hrs)


Fluids are lost during the emergent phase (first 24-72 hours), resulting in hypovolemia and hyponatremia. The blood becomes more viscous and increased hematocrit and hemoglobin values result. Cellular damage releases potassium, which causes hyperkalemia.

103

Halo external fixation device

cleaning- chlorahexadine or water
Keep vest liner clean/dry
Foam inserts under pressure points
Small pillow when supine
Keep correct-sized wrench for emergencies

DO NOT: touch device frame when positioning patients
adjust pins (HCP only)

104

Hypothermia:
The client is being rewarmed with blankets, and the IV fluids are being changed over to warmed fluids.
What additional intervention is a priority?

Attach cardiac monitor

After, get additional large bore IV and cover clients head to reduce heat loss (core takes priority over extremities)

105

Bulimia nervosa

Binge eating followed by vomiting, excessive exercise, use of laxatives.
Usually normal or just-above-normal weight.

Anorexia-
severe weight loss
bulky clothing to hide excessive weight loss.

106

Electroconvulsion Therapy

-induces generalized seizure, d/c any anti-convulsant medication
-helps treat mood disorders (major depression and bipolar) and schizophrenia

About:
NPO 6-8 hrs, driving not permitted during treatment, temporary memory loss/confusion immediate side effect, anesthesia used during procedure

107

EpiPen

Inject mid-outer thigh through clothing, hold there for 10 seconds

108

Bipolar Mania

Hyperactivity
Auditory hallucinations
Risk-taking behaviors

109

Lithium Toxicity

Normal: 0.6-1.2
>1.5 = toxicity

Risk factors: dehydration, decreased renal function (elderly), diet low in sodium, drug-drug interaction (NSAIDS and thiazide diuretics)

Acute: GI symtoms (nausea, vomit, diarrhea)
Chronic: Neuro symptoms (ataxia, coarse tremor, sluggishness, confusion, agitation)

110

Licorice Root

-herb for GI disorders
-when used with diuretics such as HCTZ, increased POTASSIUM LOSS
-risk for hypokalemia

-Pts using diuretics mostly include those with heart disease and/or hypertension

111

PPV

Positive Pressure Ventilation
-increased pressure/expansion in lungs compresses thoracic vessels
-decreased venous return, ventricular preload, and cardiac output = HYPOTENSION
-worse with hypovolemia and decreased venous tone (neuro or septic shock)

112

Necrotizing Enterocolitis

Pre-term infants
Life threatening
Underdeveloped intestines/gut immunity
Frequent abdominal girth measurements
Supine and undiapered
Avoid rectal temps (perforation)

113

Acute diarrhea
(Pediatric)

-Oral rehydration therapy (even if vomiting)
-Avoid BRAT diet
-Assess frequency/amount of wet diapers, fluid intake, sunken eyes
-Protect perineal skin breakdown using skin barrier cream

114

Uterine Rupture

-Vaginal Birth After Cesarian (VBAC) at higher risk
-1st: abnormal FHR pattern (fetal decel & brady)
***constant pain, loss of fetal station, sudden stop of contractions

Unrecognized UR: hemorrhage, hypovolemic, shock, maternal tachy

115

Nephrotic Syndrome

proteinuria
hypoalbuminemia (--fluid shift)
edema (eye, periph, ascites)
hyperlipidemia

116

Latex allergy

lip swelling from bananas, kiwis, tomatoes, peaches, grapes or avocados
latex balloons

Or rash/Itching 3-4 days after exposure to latex product

117

Isotretinoin

-Nodulistic Acne

Priority: 2 forms birth control!

More info: photosensitivity (sunscreen), blood donations discouraged, don't break capsules, dryness of eyes and mouth and skin common.

118

Using a Cane (regular and on Stairs)

Should be held on strong side!
Ex. R-sided stroke = weak left side=hold in R hand

UP: strong leg, cane, weak leg

DOWN: cane, weak leg, strong leg

Pt with total knee replacement can usually bear full weight by time of discharge

119

Placenta Previa

-Abnormal implantation of placenta. Covers cervical os (opening)

*Painless vaginal bleeding >20 wks
-increased r/f hemorrhage

RN: electronic fetal monitoring
pad counts
draw a type and screen
large-bore IV

DO NOT: vaginal/digital exam (even for dilation)

120

Long term corticosteroid therapy

Hydrocortisone
Primary drug for Addison's disease

-never stop abruptly
-notify HCP for s/s of infection
-monitor blood glucose closely if diabetic

-increase dose in times of stress
-osteoporosis
-muscle weakness
-catracts
-GI upset (take with food)

DIET: high calcium (1500mg) high protein (1.5g/kg)
Low fat, low simple CHO

121

Brachytherapy

Internal radiation via implant

-30 min total time near pt during shift
-dosimeter film badge required
-no pregos or <18 near pt
-6 feet distance for all staff
-door closed and radioactive sign outside
-private room/bathroom
-bedrest to prevent dislodgment of implant (24-72 hrs)
-shield with lead with physical contact

122

Anesthesia Pre-op Question

"Has anyone in your family had a bad reaction to anesthesia?"

MALIGNANT HYPERTHERMIA

-rare, life-threatening INHERITED muscle abnormality
-succinylcholine inhalation at start of anesthesia

-increases Ca release in muscles
--rigidity, increased O2 demand, increased temp

S/S: tachypnea, tachycardia, rigid jaw (general rigidity). Progresses to increased fever

IV dantrolene is reversal agent! Slows metabolism
Also cool client and treat hyperkalemia

123

WBC count

4,000-11,000

124

Chemotherapy Safety

-Low WBC (<4,000) likely
-Reverse/Protective Isolation (pt wears mask)
-Private room
--HEPA filtration or Pos Pressure

AVOID: raw fruits/veggies, standing water, undercooked meat, HCP's with a cold

Lowest WBC count (nadir) 7-10 days after initiation

125

Endotracheal Suction

-sterile
-hyperoxygenate beforehand
-intermittent suctioning during withdrawal only, 10 seconds
-4 or 5 recover breaths or 1-2 min b/w passes

126

Antiplatelet medications

prasugel (Effient)
clopidogrel (Plavix)
ticagrelor (Brilintal)

post coronary intervention

STOP 5-7 DAYS BEFORE SURGERY
Also stop NSAIDS (aspirin, ibuprofen, naproxen, celecoxib)
-Prolong bleeding time

Concerns:
Ginkgo biloba
Peptic ulcer disease
Bleeding disorders
Active bleeding
IC hemorrhage

127

IBS diet

Well tolerated foods: protein, breads, bland foods
-increase fiber intake as tolerated (whole grains, nuts, legumes, fruits, veggies)

AVOID: GI irritants.
Gassy foods (bagels, bananas, cabbage, onions), alcohol, caffeine, spicy foods, dairy, fatty foods

128

IBD exacerbation
and
sulfasalazine Rx

Sulfasalazine topical GI anti-inflammatory and immunomodulatory agent.

Dehydration risk of IBD.
Sulfa crystalizes in kidneys if dehydrated.
Yellow-orange discoloration of skin and urine normal for med.

PRIORITY FOLLOW-UP:
Urine specific graviey of 1.035
Normal: 1.003-1.030

IBD: increased erythrocyte sedimentation rate, WBC, and c-reactive protein normal.
Mild anemia normal for chronic inflammatory conditions.

129

SBAR

Situation
Background
Assessment
Recommendation/Request

130

Uterine Infection

Postpartum Endometritis

foul-smelling lochia
fever
chills
tachycardia
uterine tenderness

Serum lab draw for blood culture and sensitivity needed prior to antibiotic administration

131

Constipation

Common- pregos and pts taking ferrous sulfate (iron) supps

High fiber diet (nuts, seeds, fruits, veggies)
High fluid intake
Regular exercise
Bulk-forming fiber supplements
Avoid caffeine (b/c it's a diuretic)

132

Otitis media

infants and kids <2

Often follows respiratory infection such as flu or RSV

Risk factors:
Tobacco exposure
Regular pacifier use (after 6mo)
Drinking from bottle while lying down
Lack immunizations (pneumococcal series)

133

Otitis externa

excess water in ears from bathing or swimming

"Swimmers ear"

Damage due to foreign body in ear also increases risk

134

Neuro Assessment Needed if...

Nuchal rigidity (stiff neck, won't bend down)
-meningitis

Pupil dilation
-increased ICP
Normal: 3-5mm

New limb drift- stroke


NORMAL ASSESS:
positive doll's eye (oculocephalic reflex)
-intact brainstem

Absent adult Babinski reflex
-toes point down w/ stimulation on sole for negative.
Normal to fan toes (+ reflex) in infants up to 1 yr.

135

Tetralogy of Fallot (TOF)

4 defects: Ventricular Septal defect, Stenotic Pulmonary Valve, Overriding Aorta (from R/L V's), Right Ventricular Hypertrophy

-Cyanotic cardiac defect
-Infants w/ TOF normally maintain O2Sat of 64-85% until surgically corrected

-Increased HGB (polycythemia) result of compensation for hypoxia. DANGEROUS b/c increases blood viscosity.
-Stroke or thromoembolism
-Must stay hydrated

Normal Infant HGB:
12.5-20.4

136

Rapid Response Team

HR <40 or >130
SBP <90
Resp rate <8 or >28
O2Sat <90 w/ oxygen
Urine output <50 mL/4hrs
LOC change for 10 min

137

Glascow Coma Scale
(GCS)

High number is good!
Highest= 15
-Eye opening response (1-4)
-Verbal Response (1-5)
-Motor Response (1-6)

15- normal
13-14 mild
9-12 moderate head injury
<8 severe
"WHEN YOU ARE 8, YOU INTUBATE"
3 deep coma or brain death

138

ADHD

3 core sx:
hyperactivity
impulsiveness
inattention

Other:
-impaired social skills
-low self-esteem
-increased risk for depression, anxiety, learning disability, substance abuse
-academic or work failure

139

Tension pneumothorax

-progressive build up of air in pleural space
-d/t lung laceration
- no more pressure holding lungs in place, everything pulled to the opposite side!

TRACHEAL DEVIATION!
-emergency large bore needle decompression followed by chest tube placement to relieve pressure on mediastinal structures

140

Somatic Symptom Disorder (SSD)

psych disorder
stress related
unexplained physical sx

RN: redirect somatic complains to unrelated neutral topics
-limit time discussing physical symptoms

-recognize secondary gains (increased attention, freedom from responsibilities)
-recognize factors that intensify sx (stress)
-incorporate coping strategies

141

Black cohosh

Herbal supp
Menopausal hot flashes

Side effects: thickening of uterine lining, liver toxicity

142

Post cataract surgery

AVOID anything that increases intraoccular pressure:
-bending
-lifting >5 lbs
-sneezing/coughing
-rubbing eye
-straining during BM

Normal: itching, photophobia, mild pain several days post-op

143

Misoprostol

-Synthetic prostaglandin
-protects against gastric ulcers by decreasing stomach acid and increasing mucus production
-usually prescribed to pts on long-term NSAID therapy to avoid ulcers

144

Hepatic Encephalopathy

-temporary worstenig of brain function in ppl with
end-stage liver disease

-inadequate detox of ammonia from blood

Sx: lethargy, confusion, slurred speech, coma, asterixis (flapping tremor)

145

Bacterial meningitis

Most critical intervention: start antibiotic therapy!

Initiate sz precautions IF necessary, but still start therapy first.

Cause will be determined by LP and blood cultures

Complications: hearing loss, permanent brain damage, etc.

146

Monoamine oxidase inhibitors (MAOIs)

Antidepressants

common: isocarboxazid, phenelzine, tranylcypromine

-increased risk for SI
-avoid tyramine containing foods (cheese, overripe fruit, liquor, fermented foods) can cause hypertensive crisis
-sleep dysfunction
-nausea/constipation

147

Collect Sputum Speciment

1. rinse mouth with water
2. wit on side of bed
3. inhale deeply several times
4. cough deeply to raise enough sputum (4-10mL)
5. expectorate into STERILE specimen container

148

mal de ojo

"Evil Eye"
Latin American
-caused by stranger admires child
-kids vomit, fever, cry
-"cure" by admirer touching the child while speaking to the child or immedately afterwards

149

Rheumatoid arthritis
morning stiffness and pain reduction

Take warm shower or bath upon waking.

Heat decreases stiffness and promotes muscle relaxation and mobility

-ROM exercises daily to maintain joint flexibility
-Moist heat packs to stiff joints
-Ice packs to painful joints
-Frequent rest
-Sleep in flat, neutral position to keep joints straight

150

Codeine adverse effects

-constipation (drink 8 glasses water, increase fiber, laxatives if needed)
-nausea/vomiting (take meds with food)
-orthostatic hypotension (sit at side of bed before standing)
-dizziness

151

Higher Suicide Risk

SAD PERSONS

Sex (men>women)
Age (teens, young adults)
Depression (hopelessness)

Prior attempt
Ethanol/drug use
Rational thinking loss (hearing voices)
Support system loss (living alone)
Organized plan
No significant other
Sickness (terminal)

152

Phlebostatic Axis

4th IC space, mid-axillary line (close to V6)

Used as reference for placement of transducer when measuring continuous arterial BP, CVP, central line, Swan-Ganz cath, etc

153

Triple Lumen Catheter

Central Venous Catheter

Administers fluids, meds (non-compatible ok), parenteral nutrition, and used for hemodynamic monitoring (ex. CVP)

CVC=central venous cath
-inserted by HCP in 'central' vein
(subclavian, internal jugular, femoral)

Priority: check placement with chest x-ray!
Make sure tip is in lower-third of superior vena cava


Blue: IV fluids/CVP
White: TPN
Red: Blood (do not flush with saline if hemolytic rxn)

154

decompensated heart failure with frothy pink sputum

Administer diuretic (ex. furosemide) STAT.
-pulmonary edema needs to be resolved

155

Allen Test

Done before arterial cath placed.

-Have pt make fist
-Occlude radial and ulnar arteries using firm pressure
-Instruct pt to open fist
(palm will show pallor)
-Release pressure on ulnar artery
-Palm pink in 15 sec = patent ulnar artery

156

Check arterial cath

color
capillary refil
sensation
temperature
movement

Compare 2 sides or from baseline assessments

157

Possible abdominal aortic aneurism (AAA) repair complications

Pulses can be absent 4-12 hrs post-op d/t vasospasm.
If PEDAL PULSES DECREASE from baseline with cool, or mottled extremity 2 days post op, potential ARTERIAL OR GRAFT OCCLUSION.

Dangerous!!!

158

Preterm birth risks

-Infection (periodontal disease, UTI)
-#1 risk factor: Hx of spontaneous preterm birth
-previous cervical sx (ex. cone biopsy- weakens cervical support)
-tobacco and/or illicit drug use
-age <17 and >35
-malnutrition
-non-hispanic black women

159

von Willebrand disease

-Genetic bleeding disorder
-decreased vWF, needed for coagulation

Pt Teaching:
-med bracelet!
-Avoid NSAIDS
-Avoid high-risk activities (contact sports)
-keep nasal mucosa moist
-maintain gum integrity (soft bristled toothbrush)
-notify HCP s/s bleeding (severe joint pain/swelling, headache after injury, blood in urine/stool, uncontrollable nosebleed)

160

Opiod intoxicatoin

Decreased respiratory rate (<12/min)

Decreased mental status

Constricted (miotic) pupils (may not be in every pt)

Decreased/absent bowel sounds

***Naloxone (Narcan) reverses CNS and respiratory depression

Pruritus and nausea common/expected
Admin histamine blockers if needed

161

Newborn Safety

-Rear-facing carseat in back seat
-rolled blankets or car seat inserts may be used to support trunk if small baby
-supine position while sleeping
-sleep in crib in clothing, such as a sleep sack (baby warm without head covered)
-remove loose bedding and other objects from crib
-crib slats no more than 2.25 inches apart

162

Benzodiazepines

Anti-anxiety meds

alprazolam
lorazepan
clonazepan
diazepan

Take at bedtime

163

Catheter size based on fluid

BLOOD or Somewhat stable adult client needing a lot of fluid: 18-gauge

EMERGENCY: large bore, 14-gauge

General IV fluids and meds: 20-22

Children and Geriatrics w/ fragile veins: 24

164

Leukopenia
and
Neutropenia

Leukopenia: Reduced WBC count (normal 4,000-11,000)
Neutropenia: Reduced absolute neutrophil count (normal 2200-7700)

Neutropenic precautions:
-private room
-strict handwashing
-avoid exposure to sick ppl
-avoid all fresh fruits, veggies, flowers
-all equipment used disinfected

165

Pinprick fail

peripheral neuropathy

166

Loss of hair on LE

poor perfusion

likely they also have poor wound healing

167

Rheumatic Fever

2-3 weeks after streptococcus pharyngitis

Major:
J<3NES
Joints, Heart, Nodules, Erythema, Sydenham chorea

Minor: Fever, arthralgias, increased sed rate/c-reactive protein, prolonged PR interval

2 major OR 1 major + 2 minor
(+ preceding strep)

168

Feeding Tube

-Crush, dissolve, and deliver each med separately
-Determine if med in liquid form
-Flush tube with sterile water before and after med admin

169

Chicken Pox

-Varicella
-Vesicular lesions
-Airborne spread secretions
--put mask on child if in ER until placed in isolation negative airflow room
-Most contagious 1-2 days before the rash until shortly after onset (until crusted over)

170

(-) vs (+) air pressure room

Positive:
pushes air out of room by increasing rate of flow. Used for immunosuppressed clients to prevent normal environment from entering.

Negative:
ventilation system that removes more exhaust air form the room that air allowed into the room. Prevents infection from spreading out into the environment. Used for airborne spread of disease.

171

Infective endocarditis

Vegetation over valves. Can break off and embolize. Life threatening!

-prophylactic antibiotics before for high-risk procedures (ex. dental work)

-Call HCP or 911 if any sign of embolization:
*slurred speech
*ONE-SIDED weakness/paralysis/pain
*painful/cold extremity

- IV antibiotics for several (4-6) weeks post discharge

-Report persistent fever

S/S may include:
Myalgia (muscle pain), chills, fever, joint pain, anorexia, petechiae, osler node (fingers), splinter hemorrhage (nail bed)

172

Post op:
radical prostatectomy

Avoid any rectal interventions such as straining, suppositories or enemas! Prevent stress on suture lines/surgical areas.

Encourage fluid intake, ambulation (DVT), cleaning indwelling cath w/ warm water and soap.

173

Erb's Point (cardiology)

3rd intercostal space
Left sternal border

Best place to hear S2

174

Bruit

Bell of stethoscope
Swish/buzzing sounds: turbulent blood flow in a narrowed blood vessel or aneurism

175

TPN discharge plan

-change tubing q24h
-immediately report red or drainage at insertion site
-monitor temp
-capillary glucose tests

176

RACE

RESCUE anyone in immediate danger
ALARM- activate a pull station alarm box
CONFINE fire by closing doors, windows, and shutting off main O2 supply
EXTINGUISH or EVACUATE

177

line infiltration

I.V. fluid or meds leak into surrounding tissues

lumen dislodged or displaced from lumen of the vein

Usually a place of flexion or person with brittle veins

178

Injury patterns of non-accidental traumas
(Pediatrics)

- Coup-contrecoup (shaking baby, head flopping)
- Subdural and epidural hematomas
-retinal hemorrhage
-frenulum tears and gingival lesions
-linear-type immersion burns
-long bone fractures (humerus, femur)

-burns the shape of household items
-repeated injuries at different stages of healing
-lapsed time between injury and care sought
-inconsistency b/w injury and caregiver explanation
-shaken baby syndrome

179

Shaken baby syndrome

Irritability or lethargy
Poor feeding
Emesis (vomit)
Seizures

180

Advanced directives

clients choices for medical care at the end of life, including resus status

AD>family wishes

181

Second degree Type 2 Heart block

Not every P wave has QRS complex (can be ratio)
Check PR interval

Need transcutaneous pacemaker
-stop potential cardiac arrest

182

Adenosine

SVT
creates transient heartblock

183

Warts and HPV Teaching

-warts can be treated but can return
-High risk HPV strains (16/18) increase risk of cervical, oral, and genital cancers
-Vaccine <26 years of age, more effective before sexually active
-PAPs start at 21 years old EVEN IF sexually active
-barrier methods reduce risk, but don't prevent transmission

184

TB Test

Mantoux test
PPD (purified protein derivative)
Airborne

bleb 48-72 hours
>5mm induration Considered POSITIVE if:
-HIV, organ transplant, recent contact with person with TB, immunosuppressed

>10mm induration Considered POSITIVE if:
-recent arrival (<5 yrs) from high prevalent country, healthcare employees, mild immunosuppression, kids <4 yrs, comorbidities (basically unhealthy)

>15mm induration Considered POSITIVE if:
person is healthy

Redness without induration (raised hard area) is NEGATIVE.

Bacillus Calmette-Guerin vaccine increase TB resistance in increased risk pts.
Can produce false positive.

185

After positive TB test

Further test: chest x-ray if not symptomatic
Active TB: isolation and airborne N95 mask

186

Dabigatran (Pradaxa)

thrombin inhibitor
anticoagulant

Uses: atrial fibrillation, pulmonary embolus, DVT
Increased risk for: bleeding and hemorrhage

187

Phenytoin (Dilantin)

Anti-seizure medication
10-20mcg/mL

Stop enteral feedings (1-2 hr), antacids, and calcium before taking.

Early Toxicity: horizontal nystagmus
Gait unsteadiness
Later: slurred speech, lethargy, confusion, coma

Gingival hyperplasia (puffy gums)- expected side effect
Need good oral hygiene

188

Invalid Consent

If client still has questions indicating incomplete undersatnding

189

Restraints

Hourly neurovascular checks
Release for skin check and ROM q2h
Offer fluid, toilet, nutrition q2h

190

Prioritize Nurse Dx

Maslow's Hierarchy of Needs

191

Parent refuse meds or treatment

Open ended question
Assess parent knowledge first
--condition
--necessity of treatment

192

Respiratory syncytial virus (RSV)

-affects ciliated cells of respiratory tract
-excess mucus
-rhinorrhea (runny nose)
-fever, cough, lethargy, irritability, decreased feeding

Severe: tachypnea, dyspnea, poor oxygen exchange

Treatment: supplemental oxygen, suction, increase HOB, antipyretics, IV fluids, Palivizumab injection

Contact isolation, droplet within 3 ft of pt.
Transmission: DIRECT CONTACT WITH RESPIRATORY SECRETIONS.

193

Increased ICP Treatment

HOB >30 degrees
Head and body midline (promote venous return)
Stool softeners (prevent straining)
Calm environment (quiet)
Suction only when needed (no more than 10 sec)
Treat fever aggressively to decrease metabolic demands

194

Best CPR outcomes

defib early increases outcomes!
Chest clean and dry
Remove any medication patches before applying AED pads

195

Early Decelerations in Contraction Stress Test

Baby and Mom have symmetrical reactions
Onset, peak, and finish the same.

Cause: compression of head during contraction, results in vagal stimulation resulting in slowing fetal HR.
No intervention necessary

196

Late Decelerations in Contraction Stress Test

Baby onset at peak of Mom contraction.
Baby delayed compared to contraction.

Cause: Uteroplacental insufficiency, fetus has decreased oxygen reserves, maternal supine hypotension, placenta previa, abruptio placentae

Treatment: reposition mom, IV bolus, stop pitocin, give oxygen

***Needs further testing

197

Variable Decelerations in Contraction Stress Test

Random decrease (>15bpm for >15 sec) in fetal HR not associated with contraction.
R/T umbilical cord compression.

Change maternal position, check for prolapse, decrease or turn off pitocin, admin O2, prepare amnioinfusion

***Needs further testing

198

oligohydromnios

deficiency in amniotic fluid

199

Prenatal Fetal Abnormalities
*Infections*

TORCH
Toxoplasmosis
Other (parvo/varicella-zoster)
Rubella
Cytomegalovirus
Herpes

200

Chest Pain
Treatment if MI

CP=potential MI...
MI sx: CP, diaphoresis, dyspnea, anxiety

Treatment:
ABC's
12 lead, cardiac markers, electrolytes
Apply O2
Insert 2 large-bore IV's and administer medications (nitro, morphine, etc)

201

IV Potassium

Heart monitor
Monitor IV frequently (K=tissue necrosis)
Max inf rate - 10 mEq/hr (PIV)
Max concentration 40 mEq/L
Assess renal function beforehand (potential K toxicity)

202

Petichiae

-reddish/purple pin points on skin
-r/t bleeding of capillaries from blood vessel injury or bleeding disorders

Dark skin patients: conjunctivae of eyes or buccal mucosae

203

Jaundice

Increased bilirubin
Dark skinned pts- check sclera, palms, and soles

204

Administer intermittent enteral feeding

-HOB 30-45 degrees before and 30-60 min after
-Assess tube placement
-Assess bowel function (sounds and residual volume...return residual to stomach)
-Flush tube 30mL
-Administer feeding

Abd cramps? too fast or too cold

205

Abruptio Placentae

bleeding, abdominal pain, uterine tenderness, increased uterine resting tone

206

Cushing Triad

-Irregular, decreased respirations (Cheyne-Stokes)
-Bradycardia.
-Systolic hypertension (with widening pulse pressure)

Cause: rising ICP

207

High Potassium Foods

Rainbow colors!
Red- strawberry, tomato (NO APPLE)
Oranges- oranges, cantaloupe, carrots, apricot
Yellow- banana, potato
Green- avocado, kiwi
Blue from blue sea-fish
Violet-raisins

208

Low Potassium Foods

Asparagus, green beans, apples, apple sauce, green peppers, peas, grapes, grapefruit, peaches, pears, pineapple, cottage cheese, chicken, turkey, shrimp, tuna, eggs, bread, pasta, white flour, rice

209

Pre-eclampsia

New onset hypertension AND proteinuria or end-organ dysfunction AFTER 20 WEEKS GESTATION

S&S: headache, visual changes, edema (normal for all pregos)

HTN: >140/>90 on 2 occassions or 4 hrs apart
OR >160/>110 confirmed on repeat

Proteinuria: >300mg (0.3g) protein in 24-hr urine collection
OR protein to creatine ration 0.3
OR urine dipstick +1

End Organ Dysfunction:
Thrombocytopenia (<100,000)
Renal insufficiency (Creatinine >1.1)
Impaired liver function (2x normal AST and ALT)
***Normal AST 10-40/L ALT 7-56/L)
Pulmonary Edema
Cerebral or Visual Sx

210

Ostomy Care

-Change appliance 5-10 days
-Drink plenty of fluids
-Appliance needs to fit well (if loose, digestive enzymes on skin and will be irritated)
-Empty when 1/3 full
-Decrease intake of gas forming foods (onions, beans, broccoli, cauliflower)

211

Urosepsis

Bloodstream infection originating from urinary tract

Treatment:
-Fluid
-IV broad spectrum antibiotics (valsartan)
-Blood/urine culture (ideally before antibiotics)
-Heart monitor (potential hyperkalemia and sepsis)

212

Hyperkalemia
Avoid which meds?

Ace inhibitors (-pril) and ARBS (-sartan).
Used for htn secondary to renal disease.
Can worsen hyperkalemia
Don't consume salt substitutes- high in K

213

Risperidone

Use: Schizophrenia, bipolar, other mental disorders
Other atypical antipsychotics: quetiapine, olanzapine

Common S&S:
-Extrapyramidal Sx: akathesia (restlessness, fidget), parkinsonism (tremors, shuffling) *may be mistaken for agitation so watch closely
-Anticholinergic effects (dry mouth, constipation)
-Sedating Effects
-Change position frequently to prevent ortho hypotension
-weight gain

Serious S&S:
-Fever and Muscle rigidity: Neuroplastic malignant syndrome (potentially fatal)

214

Tardive Dyskinesia

repetitive, involuntary movements, such as grimacing and eye blinking

Cause: long-term use of neuroleptic drugs, which are used to treat psychiatric conditions.

215

3 P's of Diabetes

Polydipsia (thirsty)
Polyuria (>200mL/hr-increase in dilute urine)
Polyphagia (increased appetite)

216

Hyperglycemia

Polydipsia (thirsty)
Polyuria (excess dilute urine)
Polyphasia (hungry)
Headaches
Blurred Vision

TPN increases glucose, hyperglycemia = risk

217

Seizure activity RN interventions

Assist to safe position, protect head, clear area
Loosen tight clothing
Administer O2 if cyanotic
Document time and duration of sz

218

Bruising behind ear

AKA: Battle Sign
Follows head trauma
=basilar skull fracture
***Most common cause of traumatic death in kids

Other S/S: Blood behind tympanic membrane, periorbital hematomas (raccoon eyes), CSF leak from nose and ears

219

Aldosterone

adrenal glands
mineralcorticoid
RETAINS SODIUM AND WATER

Too much? fluid overload
Cushings
Hyperaldosteronism (Conns)

Not enough? Lose Na and H2O
Fluid volume deficit
Addison's Disease (ADD Steroids)

Decreased Na/H20--increase K
Increased Na/H2O--decreased K

220

ADH

Anti-Diuretic Hormone
Pituitary
RETAIN WATER WATER WATER!!!

Too much? Retain H2O in vascular space
Fluid volume excess
SAIDH- decrease urine output because ADH too high
*dilute blood concentrated urine
Decreased specific gravity and Na

*D*iabetes Insipidus- not enough ADH
D=Diuresis!!! still putting out dilute urine
NEEDS EXOGENOUS ADH
*urine diluteblood concentrated

Head trauma? Watch urine output. Potential ADH issue

221

Thyrioid Hormones

T3 - needs dietary iodine
T4 - needs dietary iodine
Calcitonin

222

Calcitonin

Decreases serum Calcium by driving it INTO THE BONES

223

Hyperthyroid

GRAVES DISEASE
nervous, sweaty, hot, wt loss, decreased attention span, increased appetite, fast GI, increased BP, increased size in thyroid (GOITER)
*exophthalmos=bulging eyes from fluid buildup behind eye. irreversible

Meds: antithyroid
propylthioracil/PTU, tapozole
Goal? EUTHYROID
Must TAPER and D/C meds!

224

Lugol's Iodine

Pre-op
Decreases vascularity to decrease bleeding
Use straw!!!

Why do we use straws? STAINS TEETH

225

Beta-blockers

Treatment for heart failure and hypertension
-olol
Decrease HR and BP (get apical pulse before admin! <50, contact HCP)
Also decreases ANXIETY
Good for Graves


MASKS HYPOGLYCEMIA- don't give to diabetics or pts with asthma

226

Radioactive Iodine

Decreases thyroid
Becomes Hypothyroid

For 24 hrs: don't go near babies or kiss anyone

227

Thyroidectomy

Teach how to support neck
interlace fingers behind neck to support
All personal items very close
No tension on sutures
Report any complaint of pressure near neck

Raise HOB to decrease edema around neck
Check for bleeding and pooling behind neck

HOARSENESS = Laryngeal nerve damage
could lead to vocal cord paralysis=trach
Keep trach set at bedside (hypocalcemia and swelling/vocal cord paralysis)

228

Parathyroid Removal?

There are 4 on Thyroid. Very possible to remove them during thyroidectomy
Parathyroid makes PTH--
PTH: increases serum Calcium by taking calcium from bones and bringing it to the blood.

CALCIUM ACTS AS SEDATIVE
No calcium? rigid, tightness, spasms

229

Hypothyroidism

No Energy/Myxedema
Babies with hypo: Sleepy, "well-behaved", barely cries, gaining weight
Adult: fatigue, slow GI, increase weight, constantly cold, slow/slurred speech, no expression.
Don't use heating pad! They might not be able to feel it.

Often confused with depression.

Treatment? Synthroid FOREVER.
Increased Energy, HR, BP.
Tent to have CAD- don't konw why
Watch for CP and rhythm changes

230

Parathyroid

CALCIUM CONTROL
***Calcium = sedative
Secretes PTH- pull calcium from bone to blood

Increased PTH- Increased serum calcium- decreased serum phosphate

Decreased PTH- Decreased serum calcium- Increased serum phosphate

Hyperparathyroidism=hypercalcemia=hypophosphatemia

231

IV Calcium

Pt needs to be on heart monitor
Decreases rate
Widens QRS- any widening STOP IV INFUSION

232

Hyperphosphatemia treatement

Amphojel
Binds phosphorus- makes phosphorus "invisible" and decreases the serum value
Leads to increase calcium

233

Adrenal Gland Components

Medulla: Epi and Norepi

Cortex: Steroids (glucocorticoids, mineralocorticoids, sex hormones)

234

Pheocromocytoma

Benign tumors releasing norepi and epi in boluses (not same amount continuously)

Increases HR and BP
VMA test (Vanillylmandelic Acid Test)
24-hr urine (discard first void, collect rest for 24 hr)
Stay calm throughout the day... no exercise, stress, etc. May alter results

Surgery to remove tumors

235

Steroids

From Adrenal Cortex
Glucocorticoids, mineralocorticoids, sex hormones

236

Glucocorticoids

protein catabolism Exogenous=decreased muscle
gluconeogenesis- inhibits insulin (CORTISOL!)
immunosuppression- decreases inflammation, slows healing
Maintains cardiac response to chatecholamines

237

Addison's Disease

Adrenal Cortex INSUFFICIENTY
ADD-ison's Disease= ADD STEROIDS
Decreased aldosterone (decrease in Na/H2O, increased K)
fluid volume loss- muscle weakness, decreased bowel sounds, nausea, GI upset, anorexia, hypotension, POTENTIAL SHOCK

*Hyperpigmentation (bronze skin)
*Hypoglycemia
***Steroids increase blood sugar
***No steroids- decreased blood sugar

Measure I and O, BP, wt -- fluid loss and med adjustment
RN Dx: fluid volume deficit

Treatment: mineralcorticoid= FLORINEF (aldosterone)

Addison's Crisis? extreme fluid loss, potential shock and vascular collapse

238

Cushing Syndrome

Disease: developed endogenously- body making too many steroids
Syndrome: exogenous administration of steroids

TOO MANY STEROIDS!!!
Exogenous glucocorticoids, minerocorticoids, sex hormones

S/S:
-hyperglycemia
-hypertension
-weight gain (truncal, buffalo hump, moon face)
-pink/purple stretch marks on abd, arms
-thinning skin, bruise easily
-muscle atrophy/weakness
-slow healing of cuts
-acne

MEN: decreased libido, ED, decreased fertility

WOMEN:
hirsutism (thicker facial and body hair)
irregular/absent menstrual period

Test: 24-hr urine

239

Prednisone

Glucocorticoid replacement

Decreases serum Calcium by making you excrete it through GI tract, pulls calcium from bones
*Calcium will look normal, but it's due to it being taken from bones
***Brittle bones!!! long term use

increase K, decrease Na, increase protein, increase calcium

240

Insulin Function

moves sugar and potassium out of vascular space into cells.
Without insulin- CELLS STARVING
Body will breakdown fat and form ketones
--ketones:acids, leads to metabolic acidosis

Insulin needs increase when pt with diabetes is sick!
illness + DM = DKA

241

Hyperglycemic Hyperosmolar Nonketotic Coma

HHNK
***TYPE 2 DIABETES

NON-KETOTIC (no ketones b/c pancreas still makes tiny bit of insulin that gets some sugar into cells)
Often confused with DKA
IS NOT ACIDOTIC!!!!
--Make enough insulin to not breakdown bodyfat (make ketones), but still extremely hyperglycemic

242

Diabetic Ketoacidosis

DKA
***TYPE 1 DIABETES!
Usually first sign someone has type 1 diabetes

-Not enough (or zero) insulin, increased blood sugar, 3 P's, fat breakdown leads to ACIDOSIS, leads to KUSSMAUL'S respirations (blow off excess CO2), decreased LOC from messed up pH.

S/S:
polyuria
abdominal pain
nausea/vomit

Treatment:
-IV insulin (d/c when glucose <200, then D5W)
-fluid resuscitation
-hourly BG monitoring
-Hypokalemia results as resolution, so admin K even when normokalemic (3.5-5)

***leads to metabolic acidosis. Can LEAD TO DEATH.

243

Pregnancy Trimester Lengths

Trimester 1: 1-13 weeks
Trimester 2: 14-27 weeks
Trimester 3: 28-40 weeks

244

3 Types of Pregnancy Signs

PRESUMPTIVE: amenorrhea (progesterone increase, not hcg), nausea, vomit, frequency (urinary), breast tenderness

PROBABLE: positive pregnancy test, hegars sign (soft uterus), goodells sign (soft vag cervix), braxton hix, pigment changes (dark line down abd), facial melasma, stretch marks

POSITIVE: fetal heart beat at 10-12 weeks
fetalscope at 17-20 weeks
fetal movement *felt by examiner*
*ultrasound*

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Gravidity

# of times pregnant

Duration means nothing here
gravida 5 with no kids is possible!

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Parity

# that reach viability
viability= 20 week minimum!!!

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TPAL

Term (>=37 weeks)
Pre-mature (20-36 weeks)
Abortions (<20 weeks)
Living

If G in front=Gravidity
If M at end= Multiple

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Naegele's Rule

Calculate Due Date

1st day LMP + 7 Days - 3 Months + 1 year

Only accurate +/- 1-2 weeks

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Pregnancy Caloric Needs and Weight Gain

400 mcg/day FOLIC ACID prior to pregnancy (neural tube defects such as spinabifida)

1st trimester: 300kcal
protein increase to 60g/day
Normal for pt to gain ~4 lbs

2nd trimester: 1 lb weight gain per week

3rd trimester: 1 lb weight gain per week

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Normal 1st Trimester S/S

nausea
vomiting
frequency (a lot of urination)
breast tenderness (all parts of pregnancy)

Drink water before topical ultrasound to push uterus to abd surface. Not necessary for transvaginal ultrasound.

VOID if an ultrasound is for a procedure

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Normal 2nd Trimester S/S

NO nausea/vomit
NO frequency
breast tenderness
quickening (fetal movement around 16-20 wks)
FHR should be 120-160

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Normal 3rd Trimester S/S

frequency back again!
edema

FHR 130-160

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Common Pregnancy Discomforts

fatigue
hemorrhoids
varicose veins
heartburn
indigestion
swelling
nausea
ankle edema (elevate)
constipated (fiber, fluids, walk)
nasal congestion (saline nasal spray)

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Prego blood pressure rule

+30/+15 of baseline!

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Danger Signs in Pregnancy

Usually 3rd trimester:
-sudden gush of fluid
-Bleeding
-Persistent Vomit
-Severe Headache
-Abd Pain
-Increased Temp
-Edema
-No fetal movement

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Leopold's Maneuver

Palpate abdomen to feel for head, back, and buttox.

WHY? Fetal back is where you listen to FHR.

VOID FIRST! Uterus should be midline

Do Leopold's Maneuver between contractions. Won't feel baby during contractions, just tightened muscles

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Labor S/S

-Lightening (fetal head dropping into pelvis) 2 weeks before.
-Mom will feel less congested
-Increased urinary frequency
-Engagement- largest presenting part of fetus (head) at pelvic inlet at zero station.
-Sudden burst of energy (nesting)
-Stronger braxton hicks contractions
-Rupture of membranes
-Soft cervix
-some women get diarrhea

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Contractions that indicate it's time for the hospital!

5 minutes apart
OR
when membranes rupture
**potential prolapsed cord, which is life-threatening

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Non-Stress Test

>=2 increases of 15 bpm with fetal movement
Each increase should last 15 seconds
20 minute test

Healthy baby result: REACTIVE! accelerations are present

If HR does not increase, baby won't be able to handle labor and delivery

Get ready for NST:
-monitor
-whenever mom feels baby move, mom punches button

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Contraction Stress Test

"Oxytocin Challenge Test"
*Only for high risk pregnancies! (pre-eclampsia, maternal diabetes, etc.)
Usually after 28 weeks because contractions being induced.
Results only good for 1 week.

Determines if baby can handle UTERINE CONTRACTIONS.
Contractions decrease blood floor to baby=potential hypoxia

Ideal Result: NEGATIVE!!! no late decels!!!

Bad Result: Late decelerations. Deliver that baby!

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True Labor

Regular contractions
Increase in frequency/duration with contractions
***Discomfort in BACK, radiates to abdomen
***INCREASED pain WITH ACTIVITY

-bloody show does not indicate true labor. Occurs a few days before onset.

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False Labor

Irregular contractions
***Lower Abdominal and Groin pain
***DECREASED pain WITH ACTIVITY (Braxton Hicks)

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Epidural Anesthesia

Position: left side, legs flexed, not a ton of back arch
-Usually no headache b/c not in spinal fluid
*Most common complication: HYPOTENSION
--IV fluids (NS or LR), change position, lie on side to decrease vena cava compression, change sides every hour

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Pitocin

Oxytocin
1-to-1 care (for NCLEX)
Never lay prego SUPINE!

Complications:
*Fetal brady- turn on left side
*Hypertonic labor- contractions that won't stop can kill baby (no oxygen getting to baby during contractions)
*Uterine Rupture: VBAC at high risk!!! C-section scar may rupture.

Complete UR: through uterine wall into peritoneal cavity. Sudden sharp/shooting pain, Absent fetal heart tones
Incomplete UR: through uterine wall, not peritoneal cavity, internal bleeding, possible late decels, hypotonic with contractions

Late Decels with Pitocin? TURN OFF!!!
Left side, oxygen 8-10 non-rebreather, bolus LR, call HCP

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Postpartum Hemorrhage Causes and S/S

Causes: uterine atony (no tone), bleeding, lacerations, retained fragments, forceps delivery

Early: >500cc in 1st 24 hrs
Late: 24hrs-6wks

High HR (should be 50-70 for 6-10 days post)
Excessive Vaginal Bleeding (>1 pad/hr)
Decreasing blood pressure (should be stable post)


*Retained placenta or any products may lead to hemorrhage
*Check firmness of fundus. If not going back to normal (involution) worry about hemorrhage!
Should be near umbilicus

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Lochia and Clots

Postpartum

Rubra (dark red) 3-4 days
Serossa (pinkish brown) 4-10 days
Alba (whitish yellow) 10-28 days/up to 6 wks
Pt teaching: report any foul smelling lochia! endometritis

Clots: no larger than nickel
Diurese for 1st 24 hours post partum
Inspect legs for DVTs

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Postpartum Perineal Care

If episiotomy, tearing, or surgery:

-intermittent ice packs 6-12 hrs to decrease edema
-warm water rinses
-sits baths 2x/day

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Breastfeeding

Initiate ASAP after birth (bonding and uterine contractions)
Breast pump if mom can't be near baby in 1st hr
Increase kcal by 500
8-10 glasses fluid/day (need more fluid/milk)
--if not, potential plugged duct and leads to mastitis
Do not clean breasts with soap, only warm water. Soap=drying
Breast pads needed. Wet breasts decrease skin integrity

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Post-partum infection

Within 10 days of birth
-E.coli
-betahemolytic strep
Will need cultures and antibiotics.
If taking antibiotics while breastfeeding, take immediately after feeding baby

Teach proper hygiene: front to back and hand washing

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Mastitis

Bacteria: Staphylococcus
Usually 2-4 weeks
Cause: not breastfeeding properly!
Need to EMPTY breast with each feeding.
Stagnant milk=inflammation

Treatment:
Still want to BF? Empty affected breast as often as possible (BF and/or pump), hot shower to help breasts leak, always offer affected breast 1st, penicillin (take immediately after feeding).
Analgesics (ibuprofen)

Don't want to continue BF: cooling breasts! Cooling breasts helps decrease milk supply and constrict vessels

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Newborn Care

Suction
Clamp/Cut Cord
Maintain Temp
APGAR (minutes 1 and 5)
***At least 8-10
**Most babies 9 because of purple hands/feet (acrocyanosis)

AquaMEPHYTON- Vit K shot in vastus lateralus
*needs clotting factors! Will make own after eating for a week
Erythromycin- eye ointment

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Baby Umbilical Cord Care

dries and falls off 10-14 days
Starts to dry in about 24 hrs
Turns black 2-3 days
Fold diaper below cord
NO IMMERSION until it falls off
report any s/s infection
wet=moist=bacteria=infection

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Baby Hypoglycemia

Not getting enough glucose from mom
High Risk: LGA, SGA, Preterm, mom was diabetic

Sugar bottle!

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Jaundice

Pathologic Jaundice: 1st 24 hrs--ABO or Rh incompatible

Physiologic Jaundice: after 24 hrs
hemolysis of excess RBC's releasing bilirubin
immature liver

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Rh Sensitization

People either have or don't have Rh factor in blood.

Rh Negative- if body exposed, will make antibodies (Rh sensitization).
Ex. Mom (-) and Baby (+), mom treats (+) like foreign body to her (-) blood.
Blood may come in contact when placenta separates at birth, during miscarriage, amniocentesis, trauma to abd.

Treatment: RH IMMUNOGLOBULIN (stops body from making antibodies). Given at 28 weeks.
*RhoGAM given after birth (within 72 hrs)
Destroys fetal cells in moms blood.

If not treated, first baby unaffected but next pregnancy could lead to complications. Mom's blood will destroy baby blood (erythroblastosis). Baby won't have blood (anemic, hypoxic), won't grow.

Baby: direct test in cord
Mom: indirect test

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Decerebrate Posture

"Extensors predominate"
***Indicates severe head/brain injury***
arms and legs straight out
toes pointed down
head/neck arched back

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Hypothermia

weak and thready pulse because of cold
should be normalized when warm
CLIENT NOT DEAD UNTIL WARM AND DEAD
may need prolonged resus

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Near-Drowning

-hypothermia common (warm IV fluids, blankets, air)
-weak thready pulses common (may need prolonged resus)
-wheezing on auscultation STILL BREATHING!
---bronchospasm
crackles=aspirated fluid- could lead to resp distress syndrome

ED management:
-advanced airway (intube and/or mech vent)
-aggressive O2
-establish IV access and IV fluids (warm if hypo)
-cardiac monitor for arrhythmias and fluid imbalances

*do not turn frequently- cause Vfib

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Renal Calculi Plan of Care

analgesia for pain
increase fluid intake
assist with ambulation (promotes clearance)
strain urine for stones (for analysis)

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Uterine Contractions
1st stage labor

45-80 seconds (NOT more than 90 seconds)
2-5 every 10 min, no more than every 2 min
Strength: measure at peak, 25-50mmHg
--NOT more than 80 mmHg
Resting Tone: measure b/w contractions
avg 10mmHg (NOT more than 20mmHg)

***Increase in values indicate uteroplacental insufficiency

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Phalen's Maneuver

back of hands together and elbows flexed

Testing for carpel tunnel syndrome

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Heel-to-Shin test

Assess cerebellar function

283

Romber test

eyes closed, feet together

Testing vestibular function (perception of head in space)
proprioception (perception of body in space)
vision

284

IV Oxytocin Complications and RN action

increased contractions, increased resting tone, increased FHR with decreased variability

Stop infusion
Reposition client to side-lying
Admin oxygen by facemask
Notify HCP
Record/Document findings

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Teletherapy

(external beam of radiation)
-Proetect skin from infection (no rubbing, itching, scrubbing, wear loose clothing)
-Cleans with lukewarm water and mild soap
-Only cream/lotion HCP approved
-Avoid extremes in temp (head pads, ice packs)

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Concussion

Minor TBI
-brief disruption in LOC
-amnesia regarding event (retrograde amnesia)
-headache

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TBI

*not concussion! More serious*
-worsening headache, vomiting, sleepiness, confusion (all indicate increased ICP)
-Visual changes
-Weakness or numbness

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SIADH

Syndrome of Inappropriate ADH
Increased ADH secretion

increased serum osmolarity, decreased serum Na
decreased urine output
increased urine specific gravity (concentrated)

OPPOSITE: Diabetes insipidus

Treatment:
fluid restriction (<1000)
oral salt tabs
hypertonic saline (at first)
vasopressin receptor antagonists
Strict I/O
Neuro checks

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Severe Preeclampsia

IV Mg prescribed (depresses CNS)

Plan of Care:
Check Deep tendon reflexes
Calcium gluconate as reversal agent
Seizure precautions!---
-Decrease environmental stimuli
-Dim lighting
-Pillow to protect head
-Side-lying position
-O2 and Suction available
-Bed in low position
-Loosened clothing

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SIRS

Systemic inflammatory response syndrome
d/t trauma, ischemia, infection (i.e. sepsis) or other distributive shock process causing system infectoin

2 of the following:
Temp >100.4 or <96.8
HR >90
Resp >28 OR pCO2 <32mmHg
WBC >12,000 OR <4000 OR >10% band

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Peritonitis

common and serious complication of peritoneal dialysis

1st: cloudy peritoneal effluent
Later: low grade fever, chills, rebound tenderness, abdominal pain

RN: collect peritoneal effluent from drainage bag for culture and sensitivity. May need antibiotics.
Do not place in high-fowlers... will increase abd pain

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Ischemic Stroke

Most common presentation: sudden onset of numbness/weakness of arm and/or leg

Kids with sickle cell at high risk (relative to other peds)

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Intussusception

One portion of intestine prolapses and telescopes into another portion

"currant jelly" stools due to blood/mucus

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Hemophilia

Primarily males
Lack of clotting factors
Desmopressin (DDAVP) stimulates release of clot factor VIII

*Pts with hemophilia A need factor VIII administered after potential bleeding injury before any other treatment.


Teach injury prevention
Avoid contact sports
Avoid aspirin and ibuprofen (platelet inhibition)
Avoid IM inj, SQ preferred
Dental hygiene to prevent gum bleeding, soft toothbrush
-MedicAlert bracelet

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Hepatic Encephalopathy

Too much ammonia! Liver not functioning to remove toxins from blood.
-Axterixis (flapping of hands)
-Fetor Hepaticus (musty, sweet breath)
-Increased ammonia levels
-Sleep disturbances/irritability
-AMS/lethargy
-slurred speech

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Theophylline

Bronchodilator
Low therapeutic index
Avoid caffeine
Monitor drug levels o avoid toxicity:
--anorexia, nausea, vomit, restlessness, insomnia
Dose based on PEAK drug levels
--measured 30 min post-dose

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Gluconeogenesis

Stress induced hyperglycemia
>140
Glucose target to void hypoglycemia is 140-180
Occurs in ICU pts when they are unable to fight off infection.
NOT always diabetic!!! 80% ICU pts with hyperglycemia not diabetic, but under physical stress

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Gingko Biloba

Taken to relieve symptoms of intermittent claudation
(cramping in leg from exercise r/t obstructed arteries)

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Cold Injury Action from Home

Rewarm in warm water (104 degrees) to promote blood flow and oxygenation
See HCP

do NOT rewarm and refreeze=death (think of chicken)
do not massage affected area!

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S3 sound

Normal in young adults and athletes
Indicates congestive heart failure in older adults

The third heart sound is caused by a sudden deceleration of blood flow into the left ventricle from the left atrium.

Heart with bell of stethoscope at apex

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Breast self exam

Not sub for routine exams!

Regular periods: 5-7 days after menstruation
Post-menopause OR irregular menses: choose same day monthly
Oral Contraceptives- when new pack started

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Post-op Prostatectomy
Concerning S/S

Contact HCP for the following:
bleeding, passage of clots, decreased urinary stream, urinary retention, S/S UTI

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NSAIDS

ibuprofen, aspirin, naproxen, ketorolac, indomethacin

---used for analgesic, anti-inflammatory, antipyretic
Toxicity: Nephrotoxic and ototoxic
TINNITUS

OD? tachy, hypotension (secondary to blood loss/dehydration from nausea and vomiting)

INCREASE risk of thrombotic events in clients with CAD

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Acetaminophen

Tylenol
Fever reducer
Pain relief

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Nitrate Medication Function

prevents angina
Vasodilate peripheral vessels and decrease cardiac workload and coronary artery workload

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Hepatitis C

Virus
Pts usually have chronic infection
Expected finding: ALT and AST (liver enzymes) >2-3x normal!

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Ventilator Associated Pneumonia

Second most common Healthcare Acquired Illness

purulent sputum, (+) sputum culture
leukocytes 12,000
fever (>100.4)
new onset or progressive pulmonary infiltrates on chest x-ray suggesting pneumonia

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Continuous Subcutaneous Insulin Infusion

-Fewer swings in blood glucose levels and hypoglycemic events
-still admin bolus before carbs
-check blood sugar at least 4x/day (4-8 common)
---Fasting, pre-meal, 2 hrs post meal, bedtime, 3am
-Open-loop cannot respond to change in glucose levels

Some closed loop with continuous BG monitoring!
Still need daily calibration

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Breast cancer
Breast lumps

Mobile lumps usually ok!

Inflammatory breast cancer: red, warm, and has orange peel (peau d'orange) pitting appearance.
Breast mass may or may not be present.
Cancer in lymph glands in affected side armpit

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Calcium needs for 1-3 year olds

500 mg/day
leafy dark greens
calcium fortified juice and cereal

Vitamin D increases Ca absorption
-direct sunlight
-fish oil, egg yolk, Vit D cereal

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Airborne Infections

Most contagious! Priority for isolation questions.
-Measles (Rubeola)
-TB
-Varicella
-Severe acute respiratory syndrome

***N95 Respirators!!!
+gowns and gloves
***Negataive airflow room

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Droplet Infections

2nd most contagious
-Viral Influenza (flu) -*and contact*
-Meningitis (Neisseria meningitidis)
-Pertussis (whooping cough)
-Rubella
-Strep group A

-Surgical mask for routine care
-Private room
-As needed: gloves, gown, goggles/face shield (wound care, suctioning)

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Contact Infections

MRSA (bathe with moistened cloths with chlorhexadine)
Scabies

314

Annual Flu Vaccine

Recommended for EVERYONE >6 months whose not allergic to ingredients

315

Prevent VAP

minimize mechanical irritation and bacterial access to the lungs
-sealed endotrach tube cuff >20cm H20 (15mmHg)
-routine oral hygiene with chlorhexidine
-elevate HOB
-avoid gastric over distension
-minimize sedation, extubate ASAP
-only suction when clinically indicated! not on schedule

316

Alcohol Intoxication Intervention

IV thiamin (Vit B1) followed by IV glucose
-prevents Wernicke encephalopathy

317

Alcohol Abuse Recovery

Should:
-show accountability
-understand/express
consequences
-use insight to face reality
-use coping skills and non-chemical alternatives.
-Encouraged to set goals for personal growth.
-Abstain from any/all alcohol consumption

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Fetal Ultrasound Timeline

7 wks- fetal heart tones
8wks- major organ systems in place/function in simple ways
12 wks- sex can be determined by genitalia if in good position

16-20 wks fetal movements felt

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Ophthalic Ointment Admin

1) Hand hygiene
2) Tilt head back, pull down lower lid, and look up
3) Squeeze thin strip onto lower lid from inner to outer edge
4) Close eyes gently for 2-3 min after application

320

Suspected Meningococcal Meningitis Nursing Care

Safety:
Droplet precautions and NPO status (for somnolence)
Comfort:
minimize stimuli, raise HOB slightly, remove pillows

Droplet precautions continue 24 hrs after initiation of antibiotic therapy

321

Loop diuretics

Furosemide (IV may cause ototoxicity, 4mg/min only)
Torsemide
Bumetanide
*used for CHF or renal insufficiency
"everything wasting"

322

Angiotensin II Receptor Blockers
ARBS

-sartan
Losartan, valsargan, candesartan
ANTI-HYPERTENSIVE

Uses:
clients who cannot take ACE inhibitors (-pril).
***No dry cough!!!
Heart failure, MI, DM neuropathy, stroke prevention

Block angiotensin 2 action.

***Angioedema can be severe and affect breathing!

*WILL NOT affect fluid status of client with acute HR.

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Beta Blockers

-lols
Metoprolol, bisoprolol, carvedilol
ANTI-HYPERTENSIVE

Decreases HR (control of tachyrhythmias), less force, therefore decreases BP

**MASKS HYPOGLYCEMIA= NO diabetics
***CONSTRICTS SOME SMOOTH MUSCLE=NO Asthmatics


Potential withdrawal

324

Ace Inhibitors

-pril
lisinopril, captopril, enalapril
ANTI-HYPERTENSIVE

First line for hypertension, especially in diabetics.
***Protective in kidneys
*-Decreases peripheral vascular resistance WITHOUT increasing HR, CO, or contractility.

DRY COUGH, angioedema
decrease aldosterone secretion=hyperkalemia (loss of H2O and Na)
--avoid K sparing diuretics (spirinolactone, amiloride, triamterene)
NO PREGO'S!!!

Check BP prior to admin.
Commonly given to pts post-MI to prevent vent. remodeling (hypertrophy)

325

Migrane

unilateral pulsating headache
sensitivity to light

326

Hypertensive encephalopathy

Medical Emergency
-caused by sudden elevation in BP (hypertensive crisis)
-leads to cerebral edema/increased ICP

-look for hx of htn, vision issues, epistaxis

S/S: severe headache, VISUAL IMPAIRMENT, anxiety, confusion, EPISTAXIS, sz, coma

327

Trismus

inability to open mouth due to a tonic contraction of muscles used for chewing

-may indicate peritonsillar or retropharyngeal abscess
-maintaining adequate airway essential

328

C. Difficile Medication

Metronidazole (Flagyl)
anti-infective drug
COMMON FOR VAG INFECTIONS
Metallic taste/dry mouth
(ok for pregos, dark urine expected)

if severe: oral vanco
IV vanco ineffective

Antibiotics reduce normal bacteria in body, alows other bacteria (like C.Diff) to take over. Grows in intestinal tract. Causes diarrhea.

329

Proton Pump Inhibitors

-zole
omeprazole, pantoprazole

Reduce stomach acid production
Take before meals

Assoc w/ development of C.diff

330

Asthmaticus

Acute exacerbation of asthma that remains unresponsive to initial treatment of bronchodilators

331

Parkland Formula

Equation needed for IV resus after burns

(4mL * wt in kg * percentage of body burned) = 24 hr requirement.
1/2 given first 8 hrs!

Convert to L if needed

332

Dilutional Hyponatrma

Na <135
Caused by excess total body water in clients with heart failure

Diuretics and fluid/salt restriction

333

Kawasaki Disease

aka: mucocutaneous lymph node syndrome

>5 days fever, bilateral non-exudative, conjunctivitis, mucositis, cervical lymphadenopathy, rash, extreme swelling, GALLOP heart rhythm, decreased UO

IV Immunoglobulin used to prevent HEART DISEASE.
Aspirin also used.
Primary goal: CORONARY DISEASE PREVENTION

334

Tricyclic antidepressants

amitriptyline, nortriptyline, desiprmine, imipramine

Common for neuropathic pain

Side effects: orthostatic hypotension, dizzy, constipation, urinary retention, confusion, photosensitivity

Pt Teaching: change positions slowly

335

Urinary Cath Care to Prevent UTIs

-routine hand hygiene
-Clean perineal area with soap and water routinely
-Keep bag below bladder and off ground
-keep cath and tubing free of kinds
-use sterile technique when collecting specimens
-encourage fluid intake if not contraindicated

Do NOT routinely irrigate
Rt use of antiseptic cleansers NOT shown to prevent infection

336

Heparin and platelets

Normally: heparin prevents clotting and does not affect the platelets (components of the blood that help form blood clots)

Immune system response sometimes causes HEPARIN INDUCED THROMBOCYTOPENIA (decreased platelets)

When pt on heparin look for and report on:
-decrease of >=50% from baseline
OR
-below 150,000

337

Advanced Directives

-Copies in med record, with pt, and healthcare proxies
-Two witnesses required, should not be healthcare proxies listed on doc
-Does not need to be notarized
-Clients wishes, not a medical order
--not a DNR form!

338

Preconception Care

-400 mcg Folic Acid
-avoid alcohol, smoking, tobacco
-dental appt in case of periodontal disease (assoc with adverse pregnancy outcomes)
-rubella vaccine 4 wks prior to pregnancy
-normal BMI (18.5-24.9)

339

Osteomalacia

REVERSIBLE bone disorder
-caused by vitamin D deficiency
-weak, soft, and painful bones

-fall precautions
-encourage light to moderate activity
-increase calcium, phosphorus, vitamin D
-Take OTC Vit D

340

Enoxaparin

low-molecular-weight heparin

Right or left side of the abdomen
At least 2 INCHES FROM THE UMBILICUS

341

Acute Pancreatitis

-life threatening
-abd pain radiating to back
-rise in pancreatic enzymes (amylase, lipase)

-Can be caused by endoscopic retrograde cholangiopancreatography (ERCP)

342

Aortic Disection

Intimal layer tears, blood between inner (intima) and middle (media) layers.

Ascending: Chest pain radiating to back
Descending: Back pain, abdominal pain

-Frequently abrupt onset
-"worst ever" "tearing" "ripping" pain
-hypertension contributing factor

Treatment: surgery and/or lowering BP

343

Septic Shock

Infectious agent from localized infection source (UTI, wound) enters bloodstream.

-Fever OR hypotherma (>100.4 <96.8)
-Hypotension (systolic <90 or MAP <65)
-Prolonged Cap Refill
-Tachycardia
-WBC >12,000 or immature neutrophils (bands) >10%
-Decreased mental status

344

Systemic inflammatory response syndrome
and
Sepsis

SIRS:
-inflammatory response
--fever, tachycardia, tachypnea

Sepsis:
SIRS + infectious source identified (pneumonia, UTI, etc)

Septic Shock:
Sepsis + HYPOTENSION DESPITE ADEQUATE IV FLUIDS

MODS:
Septic Shock + Multiple organ system damage (acute resp distress syndrome, AKI, low platelets)

345

Transurethral resection of prostate

TURP
continuous bladder irrigation for 24-36 hrs to flush small clots and prevent obstruction
-reddish-pink drainage expected

346

Obstructive sleep apnea

Apnea (>10 sec)
Diminished airflow (hypopnea)

Findings in Pt:
Night- repeated periods of apnea, loud snoring, interrupted sleep
Day- morning headaches, irritability, excessive sleepiness

347

Botulism

-muscle paralysis
-found in soil and contaminates food
-improperly canned or stored food!
-kids under 1 yr get it from honey

Manifestations:
-descending flaccid paralysis (start from face)
-dysphagia
-constipation (smooth muscle paralysis)

348

Sprained ankle treatment

"RICE"

Rest 24-48 hrs

Ice 10-15 min every hr for 24-48 hrs

Compress

Elevate 24-48 hrs

Analgesia (NSAID) every 6 hrs prn

Exercise rehab program when pain subsides

349

Peritoneal dialysys

-Cath in peritoneal cavity, dialysate (dialysis fluid) infused, tubing clamped for 20-30 min (dwell phase), unclamped to allow dialysate to drain via gravity

Insufficient flow usually from constipation blocking catheter holes!
-admin stool softeners as prescribed
-maintain bag below abdomen
-check tubing for kinks
-reposition pt (side-lying)
-assist with ambulation

350

Peak flow meter

Measures peak expiratory flow rate
-for moderate to severe asthma

Exhale as quickly and forcibly as possible through mouthpiece of device to obtain reading

-move indicator to 0 before using
-use after short-acting bronchodilator rescue MDI to check response

351

Tetracycline

tetracycline, dosycycline, minocycline

-Take on empty stomach
-Avoid antacids or dairy products (2 hrs after antacid)
-Take with full glass of water
-Photosensitivity
-Reduces effectiveness of oral contraceptives (like rifampin)

Do not take at bedtime- assoc with esophageal irritation

352

RN action for
Abdominal wound evisceration

-Remain calm and stay with pt
-Have someone notify HCP immediately and get sterile supplies
-Low-Fowlers position (<20 degrees) and knees slightly flexed
-Assess vital signs for shock (repeat every 15 min)
-Cover with sterile dressings saturated in NS
-Document
-Immediately NPO in case of surgery

353

Quadriplegia

aka: tetraplegia
Lower limbs completely paralyzed
Upper limbs completely or partially paralyzed

C-spine injury

Airway and oxygenation priority

354

Therapeutic vs. Non-therapeutic Communication

Therapeutic: reflecting, open-ended questions, suggesting strategies or resources

Non-Therapeutic: minimization, automatic responses, and leaving clients who have strong emotions

355

TPN

-Make sure CVC is in place with chest x-ray!!!
-Filters used to remove precipitate and microorganisms
-Hypertonic solution (>10% glucose) used, increases risk for infection
-0.22 micron filter used for non-lipid TPN
-1.2 micron filter used with lipids
-Baseline blood glucose and finger-sticks every 6 hrs
--- Desired 140-180 for hospitalized adult clients
-Hyperglycemia is risk, also in enteral feedings

356

Torsades de Pointes

Caused by widened QT from
Hypomagnesemia

First line treatment: IV MAGNESIUM
Defib may be necessary

Meds that can cause TdP:
heloperidol (Haldol), methadone, ziprasidone, erythromycin

357

TB intradermal injection

-Use a 27-gauge 1/4 inch needle with a 1 mL tuberculin syringe
-Administer injection on inner forearm at a 10-degree angle with bevel up
-Make a wheal (bleb)
-Avoid rubbing site after injection

358

Newborn of diabetic mother

Risk for hypoglycemia and hypocalcemia.
Hypo in newborn <40

Symptoms: JITTERINESS, IRRITABILITY, hypotonia, apnea, lethargy, tamp instability

Transitional time (first 6 hrs post birth) increased risk for hypoglycemia as fetus produces insulin in response to mom's glucose.

359

Penicillin Allergy
also avoid...

Cephalexin
any cephalosporin

Start with cef- or ceph-

360

H1 receptor antagonists

Fexofenadine
Cetrizine
Levocetrizine
Loratadine

Decrease inflammatory response by blocking histamine receptors.
-Given during type I hypersensitivity rxn (allergic rhinitis, conjunctivitis, hives)

361

Asthma and nasal polyps

sensitivity to NSAIDs

362

Sumatriptan

Selective serotonin agonist
-Treat migraine headaches
-Triptan drugs constrict cranial blood vessels to help migraine

Contraindicated in CAD and uncontrolled hypertension b/c of vasoconstriction and increased angina risk

363

Plagiocephaly

flat head syndrome in infants

-alternate head positions
-minimize time against firm surface (eg. carseat)
-tummy time for 30-60 min/day
-placing toys on opposite of favored/affected side to encourage head turning

364

Ampule medication withdrawl

-Blunt filter needle to prevent aspiration of glass
-Filter needle can be discarded and an injection needle can be attache (IM: 20-gauge, 1 in needle)

365

Expected finding in atrial septal defect

Murmur (systolic) with a fixed split second heart sound

366

Cardiac Tamponade

LETHAL!
Fluid in pericardial space
-Decreases cardiac output
*Increases CVP b/c of external pressure
*Decreases BP b/c of hemorrhage

MUFFLED/DISTANT HEART TONES
-narrowed pulse pressure
-distended neck veins
-paradoxical pulse (pulsus paradoxus): when BP >10mmHg on expiration than on inspiration
-reduced LV cavity space
-dyspnea/tachypnea
-tachycardia

TREATMENT:
Pericardiocentesis: needle to draw out blood

367

Coarctation of the Aorta

-Narrow aorta
Difference between upper and lower extremities:
UPPER- increased BP, strong brachial/radial pulses, well-developed
LOWER: decreased BP, weak/absent femoral pulses, underdeveloped, claudation (ischemic pain)

368

Anaphylactic Shock Management

Call for help!
1. Ensure patent airway, admin O2
2. Remove insect stinger
3. IM epi. Repeat dose every 5-15 min
4. Elevate legs
5. IV fluids
6. Bronchodilator (albuterol)
7. Antihistamine (diphenydramine for pruritius)
8. Corticosteroids (methylprednisolone for swelling)
9. Cricothyrotomy (tracheostomy with severe laryngeal edema)

369

Skeletal Traction tasks for UAP

-Assist with active and passive ROM
-Notify RN of sensation changes
-Remind pt to use incentive spirometer
-maintain proper use of pneumatic compression devices
-remind client to move frequently using overhead trapeze

370

Toxic epidermal necrolysis

-acute skin disorder, most commonly associated with a medication reaction, that results in widespread erythema, blistering, epidermal shedding, keratoconjunctivitis, and skin erosion
-severe form of Stevens-Johnson syndrome.
-MAJOR CAUSE OF DEATH: sepsis!! Infection=critical.

-sterile wound care
-reverse isolation and strict sterile techniques
-monitor for infection
-vital signs and output monitored for hypovolemia
-hypothermia prevention (85 degree room temp)
-pain management
-eye care

371

PTSD

-Increased anxiety
-reliving event
-feeling detached from others

3 categories of Sx:
1. Reexperiencing the event
2. Avoiding reminders of the trauma
3. Increased anxiety and emotional arousal

NO auditory hallucinations, changing emotions, delusions, or lethargy

372

Pica

compulsive craving for non-food substances

Often r/t iron deficiency anemia

CHECK hgb and Hcg levels for anemia

373

Thoracentesis

-Treat pleural effusion
-Needle between ribs into pleural space to drain fluid
-complications: pneumothorax (needle into lungs and deflates), bleeding (less common)

In case of pneumothorax watch:
level of alertness, resp rate, resp effort, O2 sat, and lung sounds.
Chest X-ray before and after

Tension pneumo= trach deviation and cardiac compromise

374

Tachysystole

>=5 contractions in 10 minutes

Do not increase uterotonic drugs (oxygocin)! Might compromise fetal oxygen.
Decrease or d/c oxytocin

375

Reye Syndrome

Encephalopathy/cerebral edema
Acute fatty liver failure

Kids cannot have:
Salicylate!!!
-Bismuth subsalicylate (pepto Bismol)
-Aspirin

...especially during a viral infection (influenza, varicella)
OR
pt with Kawasaki disease

increased serum ammonia
fever
lethargy
acute encephalopathy
altered hepatic function

376

Meds kids can have

-Acetaminophen every 4 hrs for fever

-Ibuprofen every 6 hrs for body aches

377

Delirium

"Acute cognitive dysfunction"
Manifestations in a critically ill pt who was previously A and O:
-Acute onset
-Impaired consciousness
-Fluctuates
-Reversible
-global impairment (place and time)
-short-term memory loss
-increased lethargy

378

Dementia

Gradual (months to years), consciousness intact, progressively worse, irreversible, remote memory spared

379

Depression

Gradual (months), consciousness intact, EPISODIC, reversible, moderately impared focus/concentration

380

Psychosis

No acute onset.
Usually oriented but have auditory (not visual) hallucinations
-Symptoms, not disorder (ex. schizophrenia symptom)

381

Fifth disease

"slapped face"
erythema infectiosum

Viral illness
human parvo!
School-aged kids (people pups)
-communicable only prior to symptom onset
--cover mouth and nose when coughing/sneezing

Rash on cheeks
Joint pain (ibuprofen ok!)
Recover within 7-10 days
Isolation not usually required

382

Acute blood loss

Medical emergency!
-Supine position (lower HOB) to maintain perfusion to the brain and other vital organs
-Follow this with interventions (IV access/fluids, vitals, hgb/hct)

383

Laparoscopic cholecystecomy
Post-op Nursing

-Surgical removal of gallbladder

-focuses on prevention of respiratory complications.
-Place in the SIMS POSITION to facilitate movement of carbon dioxide (CO2) utilized during surgery to fill the abdominal cavity.

384

Flumazenil

Antidose for a benzo OD

Benzo endings:
-azepam
-azolam

385

Nitroprusside

NITRO=VASODILATION

Potent vasodilator used in hypertensive urgencies

RN action: Check BP

386

Raynaud's phenomenon

Usually triggered by cold exposure
-digital arteries constrict and blood flow impaired
-red, numb, tingling, throbbing, and cold
-episodes 15-20 in

387

Physical Restraints

Limb (ankle, writs)
Belt

-involuntary
-not temporary for medical procedure (ex. elbow restraint <30 min for blood draw on toddler)

388

Post op bleeding

-Serosanguineous (pink) drainage expected
-Saturated dressing with sanguineous (bright red) indicates excessive blood loss
--posible hemorrhage
--report immediately to HCP

389

Digoxin

Lanoxin
Cardiac glycoside for heart failure and a-fib
-positive inotropic effects (increases cardiac output)
-negative chronotropic effects (decreases heart rate)
-Range 0.5-2.0

*Prior to admin check pulse (<60) hold med

Report:
Cardiac Sx
Visual changes (scotomas, blindness, color vision)
GI changes (nausea, vomit)
neuro manifestations (lethargy, fatigue, weakness, confusion)

390

Chest Tube sections

Left to Right:
A: Suction Regulation
Suction control chamber: amount of suction applied
Continuous, gentle bubbling

Water Seal Chamber (middle)
BUBBLING IS BAD HERE!
C (low part): Air leak gauge. Bubbling indicates air leak.
B (tall 2 balls): Should see inspiration and expiration *tidaling*

D: Collection Chamber
Collect drainage from client (serosanguinous). Not bright red1

391

Strong Antibiotics and Risks

Vancomycin
Gentamicin (aminoglycosides)

Nephrotoxic
Ototoxic

Constantly check kidney and hearing function

Vanco: red man syndrome- upper body flushing

392

Statin and Fibrate Complications

Statin: atorvastatin, rosuvastatin
Fibrates: gemifibrozil, fenofibrate

Muscle aching and cramping.

Statins: take at night or before bed
-most cholesterol synthesized during fasting state, so statins needed in system at that time
-Contraindicated for severe liver or muscle injury

393

Methotrexate

-Treats cancer, RA, psoriasis (malignancies)

-Immunosuppressant
---increased risk for infection
-Decreases RBC
---bone marrow suppression
-teratogenic NO PREGOS!
-Hepatotoxic, avoid alcohol!

394

CVP

-Central venous pressure
-Right Ventricular Preload (volume in V at end of diastole)

Normal: 2-8 mmHg

Increased indicates fluid volume overload:
-periph edema
-increased dilute urine output
-acute rapid wt gain
-JVD
-S3 heart sound in adults
-tachypnea, dyspnea, crackles in lungs
-bounding periph pulses

Low CVP:
deficient fluid volume:
dry mucous membranes, hypotension

395

Nicardipine

Cardene
Potent Calcium Channel Blocking Vasodilator

Priority RN intervention is to monitor hypotensive effects of drug

396

Acute stroke presentation

requires "permissive hypertension" during the first 24-48 hours to allow for adequate perfusion through the damaged cerebral tissues.

397

Guillain-Barre Syndrome

Rare disorder
Immune system attacks nerves
Ascending paralysis
-weakness
-ataxia
-bilateral paresthesis progressing to paralysis

Progresses rapidly or over 2-3 wks

398

Active labor

"transition:
8-10 cm
Bloody show
Urge to push (Ferguson reflex)
Coach through breathing techniques and AVOID PUSHING until fully dilated to prevent cervical tauma

399

ACE inhibitors and ARBs

-prils
-sartans

***May potentiate hyperkalemia***

ACE- decrease aldosterone (promotes Na retention and K excretion)

400

Lactulose

Cirrhosis and hepatic encephalopathy

Promotes excretion of ammonia via fecal elimination

401

Orthostatic BP Procedure

1. Have the client lie down for at least 5 minutes
2. Measure BP and HR
3. Have the client stand
4. Repeat BP and HR measurements after standing at 1- and 3-minute intervals

402

Greasy, foamy, foul-smelling, fatty stool

chronic pancreatitis

403

Light gray "clay-colored" stool

Bilary obstruction

404

Small, dry, rocky hard masses for stool

constipation

405

Black tarry stool

"coffee ground stool"
aka: MELENA
Upper GI bleeding
NSAID overuse

406

Bright red bloody stool

Lower GI bleeding

407

Blood present on surface of stool

hemorrhoids

408

Diabetic foot care

Keep clean, dry, and free from irritation

1. wash feet daily warm water mild soap
2. inspect for abrasions, cuts, sores
3. to prevent injury, use cotton or lambs wool to separate overlapping toes, but nails straight across and file along cures of toes, do not go barefoot, mild food powder for moisture, absorbent socks with aligned seams
4. avoid OTC products on abrasions
5. do not sit with legs crossed, exercise daily
6. report any issues/infections immediately

409

Cast Care

Nothing placed down cast! No lotion. No powder.
Use cool hairdryer to help itching.

S/S of infection (sores, purulent drainage, foul odors) and persistent itching report to HCP.

Frequent neurovascular checks if pt has vascular impairment (changes in extremity color, temp, pulse) or periph neuro impair (loss of sensory or motor function)

410

Alcohol Withdrawl

-always screen for heavy use of alcohol or benzodiazepines as withdrawal is potentially life-threatening and avoidable.

Mild 6-12 hrs: anxiety, insomnia, tremors, diaphoresis, palpitations, GI upset, intact orientation

Seizures 12-48 hrs: single or generalized tonic-clonic
Hallucinations 12-48 hrs: visual, auditory, or tactile, intact orientation, stable VSs

Delirium tremens 48-96 hrs: confusion, agitation, fever, tachycardia, hypertension, and diaphoresis, hallucinations
DT's can be prevented with benzo administration

Benzo's used to help with withdrawl. -epam

411

Features Assoc with Hip Fracture

Ecchymosis/tenderness
Groin and hip pain with weight bearing
**Muscle spasm*** for protection and stabilization
Shortening
Abduction or adduction of the affected
External rotation

412

PTSD

Re-experiencing the traumatic event:
Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (eg, rapid, pounding heart; gastrointestinal distress; diaphoresis)

Avoiding reminders of the trauma:
Examples include avoidance of activities, places, thoughts, or other triggers that could serve as reminders; feeling detached and emotionally numb; loss of interest in life; inability to set goals; and amnesia about important details of the event

Increased anxiety and emotional arousal
Examples include insomnia, irritability, outbursts of rage, persistent anger and/or fear, difficulty concentrating, hypervigilance, and exaggerated startle response

Persons with PTSD are typically restless and hypervigilant and have trouble falling or staying asleep.

413

Breastfeeding

on demand, whenever infant displays hunger (crying rooting reflex)
8-12x/day

15-20 min/breast for newborns

"tummy to tummy" at nipple level

Common positions are clutch hold, cradle, cross cradle, and side-lying

nipple and part of areola

Incorrect latch: insert a finger to break the suction prior to moving infant

414

pudendal nerve block

Used when too late for epidural!
Late Second Stage of Labor

-infiltrates local anesthesia (ie, lidocaine) into the areas surrounding the pudendal nerves that innervate the lower vagina, perineum, and vulva.
- least maternal/newborn side effects
-It does not relieve contraction pain but does relieve perineal pressure when administered in the late second stage of labor

415

Otitis Media
vs
Otitis Externa

Otitis Media:
-usually kids <2 after resp infection
-high fever, ear pain, irritability/restlessness, loss of appetite, and pulling on the affected ear
-bulging red tympanic membranes

Otitis Externa:
-swimmers ear
-infection of outer ear
-severe pain experienced with direct pressure on tragus (anterior flap Rose has pierced) and pinna (whole outer ear)
-normal tympanic membrane, infection in external ear canal,

416

Meniere disease

endolymphatic hydrops
***excess fluid in inner ear
-vertigo attacks (minimize with quiet, dark room and avoiding sudden head movements, turn off TV)
-tinnitus
-hearing loss
-aural fullness

417

ALT/AST test indications

LIVER INJURY!
-HEPATITIS/other hepatic disorders
-Viral hep
-excess alcohol intake
-OTC meds (acetaminiphen), -certain herbal and dietary supplements (green tea extract, kava, comfrey)
-IV illicit drug use (increases risk for hep B/C)

418

Target range for glucose control in pts receiving nutritional support

140-180
Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) can be due to slowing the rate of the infusion.
Although it occurs less frequently in clients receiving total parenteral nutrition (TPN) than hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) does, hypoglycemia can lead to life-threatening complications
(eg, seizures, nervous system dysfunction).

419

Otalgia

Ear Pain

Normal after adenotonsillectomy due to irritation of the 9th cranial nerve (glossopharyngeal) in the throat.

420

Hypertensive Crisis

Elevation in blood pressure (BP) >180 mm Hg systolic and/or >120 mm Hg diastolic
***evidence of organ damage (eg, kidney damage, retinopathy).

RN: Prioritize Neurological Assessment b/c of stroke risk

Goal: slowly lower BP using IV antihypertensive medications (eg, vasodilators) to limit end-organ damage.

421

Clodine

Very potent antihypertensive
Abrupt D/C can result in serious rebound hypertensive crisis

Other common side effects:
3 D's
Dizziness
Drowsiness
Dry mouth

422

Isoniazid (INH)

-is a first-line latent tuberculosis (TB) drug


Adverse Side effects:
HEPATOTOXICITY
PERIPH NEUROPATHY (interferes with Vit B6 aka pyridoxine)

Avoid alcohol
Avoid other hepatotoxic agents (acetaminophen)
Take pyridoxine (Vit b6)
Avoid aluminum-containing antacids (Maalox)
Report vision changes

Report S/S of severe adverse effects:
Hepatoxicity (jaundice, vomiting, dark urine, fatigue)
Peripheral neuropathy (numbness, tingling of extremities)

423

Dumping syndrome

-complication of the surgically reduced gastric capacity (ex. Billroth II, gastrojejunostomy).
-rapid emptying of hypertonic gastric contents into the duodenum and small intestine.
-abdominal pain, diarrhea, nausea, vomiting, dizziness, sweating, palpitations (tachy), hypotension.

Dietary changes to delay gastric emptying:
Small frequent meals
Foods high in protein and fat
Drink fluids between means
Avoid high carbs (dry foods with low carbs ok)
Diet high in fiber
East slowly
Avoid sitting up after a meal

424

Baby Ultrasound Timeline

7 wks- fetal heart tones
8 wks- major organ systems in place (function in simple ways)
12 wks- sex if in good position
16-20 - quickening (fetal movement)

425

Near Drowning ED

-advanced airway management (intub/MV as needed)
-agressive O2
-Establish IV access/IV fluids (warm if hypothermic)
-Monitor heart arrhythmia and fluid imbalances

Frequent turning-cause Vfib

426

Baseline glucose for hospitalized adult

140-180
>180 hyperglycemia
<70 hypoglycemia
<100 should be avoided

427

Torsades de Pointes

widened QT
HYPOMAGNESEMIA
Treat with IV Mg and maybe defib

428

Compartment Syndrome

post-op/post fracture reduction
Neurovascular checks performed 1st
*****If pain NOT RELIEVED by pain meds or is out of proportion to injury notify HCP*****

Early S/S: pain, numbness, unrelieved pain by meds, diminished/absent pulses, pallor, coolness, cyanosis

Put extremity LEVEL WITH HEART (not above)
Do NOT apply heat/ice

429

Sodium Polystyrene Sulfonate

Kayexalate
Retention enema
Given to pts with increased K levels
Resin in SPS replaces Na for K

430

Barium enema

Contains contrast for colon in fluoroscopic x-ray

431

Fleet enema

Hypertonic solution, pulls H2O from bowel, softens stool, then defecation

432

Neomycin enema

Medicated
Decreases bacteria before colon surgery

433

SLE

positive antinuclear antibody titer (>1:40)
elevated erythrocyte sed rate (normal <30 mm/hr)
Lupus nephritis (treat ASAP to preserve kidneys)
--increased serum creatinine >1.3 Increased BUN

Butterfly (malar) rash
Photosensitivity
Rash anywere exposed to sunlight
Weight loss
Fever/increased infection
Raynaud's phenomenon (cool/numb parts in certain situations. Think of holding snowball)

434

Polycythemia Vera

-Excess amt RBC, WBC, and platelets produced
-Bone marrow disorder
-Increased risk for clots b/c of increased volume, vascular stasis of blood

***Periodic phlebotomy to remove 300-500mL blood through venipuncture***

Pt should report swelling, redness, or tenderness in leg
Follow up immediately
Stroke also complication

435

Mitral Valve Regurgitation

LV pumps blood through aorta and some backflows into LA
-Decreased CO
-Dilation of LA
-Pulmonary edema
-Often asymptomatic
-Report any new sx of heart failure
***dyspnea, orthopnea, weight gain, cough, fatigue)
HEART FAILURE REQUIRES IMMEDIATE INTERVENTION

436

Heart Failure
Diastolic and Systolic

Diastolic: Heart can't fill (stiff thick chambers/impaired relaxation)
Systolic Heart can't pump (reduced Ejection Fraction)

437

Cervical Cancer Risks

HPV and anything that increases risk to get HPV

-sex before 18
-multiple partners
-immunosuppression
-oral contraceptives
-STDs
-Tobacco use

438

Kernig's Sign

(+)=MENINGEAL PAIN
pt supine
flex pts hip and knee
try extending leg at knee
(+)= back pain and resistance to straightening
Bilateral = even more (+)

439

Brudzinski's Sign

(+) MENINGEAL IRRITATION
pt supine
put hand behind pts head
lift head (flexing towards chest)
(+)= INVOLUNTARY FLEXION OF HIPS AND KNEES

440

Otalgia

Ear Pain

441

Hypertensive Crisis

>180 and/or >120mmHg + organ dysfunction

Goal: slowly lower BP using IV antihypertensives

442

Amlodipine

Calcium channel blocker
Used for HTN
Slows HR
Relieves CP

443

Hemianopsia

Only portion of visual field from each eye
R-sided CVA may have L-sided hemianopsia
Turn head to left to see more of visual field

444

Tiotropium

and Umeclidinium
Inhaled steroids
Powder via special inhaler
-long acting 23-hr anticholinergic med
Rinse mouth out afterwards

do NOT decrease inflammation, but RELAX airway by blocking parasympathetic bronchoconstriction

445

Ipratopium

Short acting anticholinergic used as a RESCUE for COPD/ASTHMA


do NOT decrease inflammation, but RELAX airway by blocking parasympathetic bronchoconstriction

446

Epiglottitis

aka: supraglottitis
Sudden-onset medical emergency due to Haemophilus influenza.

-Soar throat
-Fever w/ toxic appearance
+ 4 D's:
-dysphonia (muffled voice)
-DROOLING
-dysphagia (difficulty swallowing)
-distressed resp effort

RN action: tripod position
-will need intubation or surgical airway
PREVENTABLE!!!
Cause: Haemophilus influenza type B (HiB)
standard 2- and 4-month vaccine
Rarely seen in vaccinated kids

447

Ethambutol

TB drug
OCULAR TOXICITY (vision loss/double vision/blurred vision)

Loss of red-green discrimination
Monitor eyes regularly (baseline eye exam)

448

Sucralfate

Antacid
Take before meals to decrease irritation of ulcers

449

Coombs Test

Screens for Rh sensitization
Indirect Coombs Test: mom
Direct Coombs Test: baby

Rh (-) mom will get screened if any TRAUMA occurred that may cause bleeding.

Rh immune globulin (RhoGAM) given to ALL Rh (-) pregos at 28 weeks and within 72 hrs of birth as well as post maternal trauma
NOT EFFECTIVE once sensitization has ccured

450

Serum alpha-fetoprotein

Screen for neural tube defects

451

Rubella

German Measles
red rash
Droplet (sneeze, cough, mucus/saliva contact)
Mom to baby by pregnancy, labor, nursing

MMR VACCINE!!!
Measles, mumps, rubella

452

Meningitis

fever, severe headache, nausea/vomiting, nuchal rigidity, photophobia, AMS, increased ICP

-W/ sepsis or hypotension? FLUID!
-vasopressors (constrict blood vessels) epi, norepi
-Labs/cultures
-Empiric antibiotics (within 30 min admission)
-Head CT BEFORE LP (increased ICP or mass lesions lead to brain herniation)
-assist with LP

453

NERVES

Oh Oh Oh To Touch And Feel A Girls Vag Ah Heaven

I-Olfactory-Smell
II-Optic-visual
III-Oculomotor- pupils constrict/extraoccular movement
IV-Trochlear- extraoccular/down and inward
V-Trigeminal-Clench teeth and light touch
VI-Abducens- Extraoccular/ lateral movement
VII-Facial- Close eyes and smile
VIII-Acoustic- Hearing/Romberg
IX-Glassopharyngeal-Gag reflex
X-Vagus-"AH" uvular and palate movement
XI-Accessory (Spinal)-Turn head and shrug shoulders
XII-Hypoglossal-stick tongue out

454

Metabolic Syndrome

>= 3 health factors
Increase risk for Stroke, DM, and CVD

-Abdominal Obesity (>40M, >35W)
-Increased Triglycerides (>150) R Hypertriglyceredemia drug treatment
-Decreased HDL (<40M, <50W)
-HTN (>=130/85) OR hypertensive drug treatment
-Fasting blood glucose >=100 OR hyperglycemia treatment

455

Lumbar Puncture

Spinal Tap
Increase fluids
lie flat for 4 hrs (prone or supine)
Headache common
Continued leaking fluids- site not sealed! Blood patch needed

456

Ankylosing Spondylitis

Inflammation disease
Hunch/curved spine

-posture, daily stretching, swimming or racquet sports
-stop smoking/breathing exercises
-pain: moist heat and NSAIDS
-immunosuppressant and anti-inflammatory meds
-rest during flare ups
-sleep on back with FIRM mattress to decrease spinal flexion

457

Cleft Palate

Risks: aspiration, malnutrition
Inability to create suction

Feeding:
-upright
-bottle/nip away from CP
-special bottle (nip always filled) "cross-cute" and preemie nips (no sucking needed)
-burp often
-feed slowly 20-30 min
-feed 3-4 hrs

458

Beck Triad

Cardiac Tamponade

Hypotension
Muffled heart sounds
Distended neck veins

Pulsus Paradoxus: large decrease in stroke volume, SBP, and wave amplitude during inspiration
"Normal" SBP fall: 10 mmHg
Normally BP rises with inspiration and falls with expiration

459

Acid-fast Bacilli Smear and Culture

Confirms TB after positive TB test and Chest x-radiograph

Sterile sputum 3 consecutive mornings

460

Chronic Arterial Insufficiency

*Oxygenated Blood Not Getting To Tissue*

Pain: Intermittent claudation (progresses to rest pain)
Pulses: Decreased or maybe absent
Color: Pale when elevated, red with lowering of leg
Temp: Cool
Edema: Absent or mild
Skin Changes: thin, shiny, loss of hair over food/toes, nail thickening
Ulceration: If present will involve toes or areas of trauma on feet (painful)
Gangrene: May develop
Compression: Not used

461

Chronic Venous Insufficiency

*Blood Getting To Tissue, Can't Get Away!*
--Not oxygenation problem (don't choose give 2L NC)

Pain: None to aching pain depending on dependency of area
Pulses: Normal (may be difficult to palpate d/t edema)
Color: Normal (may see petechiae or brown pigmentation w/ chronic condition)
Temp: Normal
Edema: Present
Skin Changes: Brown pigmentation around ankles, possible thickening of skin, scarring may develop
Ulceration: If present will be on sides of ankles
Gangrene: Does not develop
Compression: Used (need fluid to get back!)

462

Cardiac Output

Amt of blood pumped by the heart per minute

HR x SV (bpm x amt per beat)

463

Preload

End Diastolic Volume
Stretches R or LV
CVP=measurement (2-8 normal)

464

Afterload

Pressure in aorta and peripheral arteries that LV has to pump against during systole
(systolic pressure)

465

Fibrinolytics

Dissolve clot blocking blood flow to heart
Decrease size of infarction

Streptokinase (a lot of peopel allergic)
Tenecteplase (1x psh)
Aletplase (stroke too!)
Reteplase

Heart: 6-8 hrs!!!

Complication? Bleeding

Contraindications:
Brain tumor (IC neoplasm), IC bleed, suspected aortic dissection, internal bleeding

Stroke: 3 hrs

466

5 P's

Neurovascular Check:
Pain
Pallor
*Pulselessness (mark before procedure)
Paresthesia (tingling, burning, etc.)
Paralysis

467

CHF

Coronary Heart Failure

Blood not moving forward (cardiomyopathy, valvular disease, endocarditis, acute MI, htn)

Left sided: THINK LUNGS!
pulm cong, dyspnea, S3 sound, restless, blood-tinged sputum, crackles, Displaced PMI, paroxysmal nocturnal dyspnea (sense of SOB that wakes up pt)

Right Sided: "Cor Pulmonate"
Think Venous system
enlarged organs, pitting edema, wt gain, distended neck veins (JVD), ascites

468

Diagnose CHF

Swan Ganz catheter
Central line cath
-measures pressures inside of the heart

Not pumping? increased heart pressure will show with increased Swan reading

Other Tests:
High BNP (peptide released when Vent stretched)
Chest X-ray- enlarged heart, pulm edema
Echo- EF, measures pressure

469

Systolic HF vs Diastolic HF

Systolic: Heart can't contract/eject
Diastolic: Ventricles can't relax and fill

470

Spironolactone

Aldactone
Diuretic
May be given to decrease aldosterone (salt and water) levels

When H2O and Na decrease, K increases!!!

K-SPARING!!!!!!!

471

Artery vs Vein
Elevate extremity?

Elevate Veins
Dangle Arteries

Artery issues/occlusions prevent blood from getting to tissue. Elevation makes that worse

Veins can't get fluid away from tissue, elevate to move fluid along

472

Buerger's Disease

Arterial Disease
Men
inflammation of veins and arteries (mainly arteries)
--Cuts off O2
Usually LE's (toes)

Cause? Heavy smoking, getting too cold, intense emotions

Treat: stop smoking, avoid cold, hydrate, wear shoes that fit well, maybe surgery, avoid trauma to feet

473

Raynaud's Disease

Arterial Disease
Female=Fingers!
Vasoconstriction of vessels.
Get's upset/cold/smokes and her fingers (both hands) turn white, then blue, then red
PAINFUL and can ulcertae

Avoid cause: ex. if hands hurt when reaching into the freezer, wear gloves

474

Echolalia

Repeating word or phrase over and over
"echo"
one of many schizo symptoms

475

Neologism

Make up new words with no real meaning
"neo-logic"
one of many schizo symptoms

RN: seek clarification!" "I don't understand"
Do not reinforce behavior

476

Korsakoff's Syndrome

Common in alcoholism
*Thiamin/Niacin (V Vits) deficiencies

Disoriented to time
Confabulate (make up something to fill in gaps)
--memory disturbance

477

Wernickes Syndrome

Common in alcoholism
Thiamin (Vit B1) deficiency

labile emotions
moody
tires easily
ok at first, ten soemthing sets them off

478

Antabuse

Deterrent to alcohol
--any type of alcohol will cause effect
--couph syrups, aftershave, colognes,e tc

479

Hemothorax

Blood in pleural cavity

NOT pneumothorax= air in pleural cavity

480

Crutches on Stairs

UP:
"Up with the Good"
Strong leg, weak leg, crutches

DOWN:
"Down with the Bad"
Crutch, bad, then good

481

Walking with Walker

Pick up, put in front, walk into walker

Sliding? Hazard if pt's walker has rubber stoppers. They need tennis balls to make sliding safer

482

D-Dimer

Blood test
Will increase with pulmonary embolism
*Indicates if clot located ANYWHERE in body, not just lungs

483

hemoptysis

coughing up blood

484

Fractures:
S/S
Complications

Continuos pain, unnatural movement, muscle spasms, possible deformity, crepitus (bones grating together), shortening of extremity (r/t muscle spasms), swelling, discoloration

Complications: Shock, Compartment Syndrome, Fat Embolus (usually long tone fx, pelvic fx, crushing injury)

485

Fat Embolus S/S

Depends on where emboli travels:
-petechia or rash over chest
-conjunctival hemorrhage
-"snow storm" chest x-ray (fat in lungs)

First 36 hrs post injury

486

Traction

-Pulling on part of body
-Decreases muscle spasms, reduces (realigns) bones, immobilizes
-Should be continuous *never relieve traction w/o order!*
-Weights hand freely
-Ropes move freely
-Knots should be secure

Skin Traction: tape material stuck to skin and weights pull against it. Skin not penetrated!
Bucks, Russell's

Skeletal Traction: applied direclty to bones w/ pins and/or wires. Used when PROLONGED traction needed
Steinman Pins (through the knee), Gardner-Wells Tons, Halo Vest

487

Skin Traction Types

BUCKS--mostly hip fx
-Weights hang off end of bed
-1 pulley and food being pulled horizontally towards end of bed

RUSSELL'S- moslty femoral fx
-3 pulleys
--1 above knee to pull leg upward while also being pulled by 2nd pulley towards end of bed

488

Post-Op Amputation

-Tourniquet at bedside in case of hemorrhage
Elevate on pillow first 24 hours
--after that, elevate food of bed! (don't want contractures)
-Want to prevent hip flextion!!!
BKA=2 possible contractures (hip/knee)
--put pt in PRONE POSITION to extend hip.knee
Phantom Pain- diversional activity and pain meds

Rehabilitation:
-Stump shaping for prosthesis-cone shape
-Massaging stump increases circulation and decreases tenderness
-"Toughen" Stump: press into soft pillow, then firm pillow, then the bed, then the chair

489

Hemodialysis

-Machine acts as glomerulus
-If pt allergic to HEPARIN, can't be hemodialyzed
---unless another solution with anti-clot property can be used (ex. sodium citrate.
-Pts with unstable cardiovascular system can't tolerate hemodialysis

-Done 3-4x/week
-Avoid K, high Na, and Phosphorus in diet
-Eat more protein
-Learn how much fuid allowed to drink

490

Glomerulonephritis

-Inflammatory rxn in GLOMERULES (kidney filter)
-Usually caused by STREP
-sore throat, malaise, headache, Proteinuria, increased BUN/Creatinine, facial edema, decreased UO, anemia

-Increase Carbs to increase energy! Dn't want protein to break down and make Urea that can't be excreeted

491

Nephrotic Syndrome

*Inflammatory response in glomerulus
ANY INFLAMMATION! (NSAIDS, heroin, Hodgkins, bacteria, viral, allergic rxn, DM, SLE)
*big holes=protein leaking into urine
*hypoalbunemic - can't hold onto fluid in vessels-THIRD SPACING!
*Full-body edema (ANASARCA)
*No fluid in vessels=kidney response to increase fluid-(renin-angiotensin system kicks in and produces aldosterone)
*retention of Na and H2O

Bed rest (to diurese)
Prednisone- decrease inflammation (now immunosuppressed)
***Increase protein! ONE KIDNEY DISEASE YOU CAN INCREASE PROTEIN

Lasix and Albumin infusion

492

Meds that could cause intra-renal damage

"MYCINS", loop diuretics
-use with caution in clients with renal damage

493

Peritoneal Dialysis

-Dialysate WARMED (vasodilation) and infused into peritoneal cavity by gravity through catheter
-2000-2500 mL stays in for ordered amt of time (dwell time)
-Bag lowered and fluid along with toxins drained

Effluent/drainage/fluid:Should be clear, straw-colored
Cloudy=infection!

-WHO? Pts who can't take hemodialysis like cardiovascular pts

-Fluid not coming out? Reposition or turn from side to side
-Diet: increased fiber and protein

2 Types of Peritoneal Dialysis
-Continuous Ambulatory Peritoneal Dialysis (4x/day, 7 days/week, need strong client with no disc disease, arthritis, or colosomy)
-Continuous Cycle Peritoneal Dialysis (night time only)

494

Continuous Renal Replacement Therapy

Usually ICU setting
-kidney filter utilized
-Hemodialysis more aggressive
--300mL of blood in hemo machine, only 80mL in CRRT machine
-Better for unstable pts whose CV status can't handle hemodialysis

495

Ultrafiltration

Only pulling off water for pts only retaining water
May be utilized with peritoneal dialysis or hemodialysis

496

Kidney Stones

Renal calculi, urolithiasis
Don't Kill You!
Pain
WBC's in urine
Hematuria (not inough to throw you in shock)
RN Action: Urine specimen ASAP and check for RBC's

Treatment:
-Ketolorac (Toradol), Hydromorphone (Dilaudid), Promrthazine (Phenegran), Ondansetron (Zofran)
-Increase fluids
-Strain urine

-EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL)
Will CRUSH stone!

497

Cups of milk for 14 month old daily?

2-3 cups

498

School age child daily caloric intake?

1600 avg
based on weight

499

FLACC assessment

Pain assessment
2 months - 7 months

Face
Legs
Activity
Crying
Consollability
0=no pain
10=worst pain

500

Wong Baker Pain Rating Scale

Faces :)
>=3 Years

501

Numeric Scale for children of what age?

>=5 Years old

502

Pediatrics
Observable signs for respiratory dysfunction

Accessory muscle use
Flaring nostrils (nares)
Circumoral pallor
Sternal retractions
Pallor
Cap refill >3

503

Respiratory Syncytical Virus

RSV
-Acute viral infection affecting bronchioles
-Affects children 2 months-2 years
-Begins with simple URI and then progresses
-nasal discharge, nonproductive paroxysmal cough, tachypnea and flaring nares, wheezing

504

Asthma
S/S and Dx

Cough, SOB, audible wheezing, prolonged EXPIRATORY WHEEZING, restlessness, cyanosis, tripot posiiton

Identify triggers!!!

Infants: Reactive Airway Disease (RAD)

-Chronic cough, no infection
-Pulmonary Function Test
-Spironmetry function >5 years old
-Peak expiratory flow rate (PEFR) (age, race, height gender dependent)

505

Asthma Treatment

GENERAL:
-Chest physiotherapy (percussion, vibration, squeezing of chest and then breathing exercise- ex. blowing a pin wheel)
-allerg shots
-small frequent meals
-cold air, breath through nose
-encourage fluids to thin secretions (not cold- bronchospasm)

ACUTE:
-humidified O2
-epi Sq or Tebutaline Sq
-Rescue meds: IV corticosteroids, prednisone, Solu-medrol
**Beta 2 agonists: Albuterol, Metaproterenol, Terbutaline
--After neb treatment, kid will get worse before better. Airway opens and they will wheeze
**Bronchodilator: Salmetrol, aminophaline, theophylline

LONG TERM CONTROL (preventer meds)
-corticosteroids (inhaled by MDI or neb, po)
0MDI's
-Beta 2 agonist

***MDI at any age with correct spacer

506

Hirschprung's Disease

Piece of intestines=no nerves
No nerves = no peristalsis in that location
AKA: aganglionic MEGA COLON that results in mechanical obstruction along bowel.
-Sigmoid Colon
S/S- Constipation, abdominal distention, ribbon-like/foul smelling stools

507

Pyloric Stenosis

Obstruction of gastric outlet.

-Results in projectile vomiting d/t pressure, usually after feeding.
-Immediately hungry again.
-Olive shaped mass in epigastrium region (near umbilicus)
--Enlarged pyloris's!

Vomiting=dehydration
-metabolic alkalosis
-hypokalemia
-hemoconcentration (high hct)

RN Intervention for infant pt?
hydration d/t vomiting, intake and output, daily weight, urine specific gravity

Surgery neeeded

PS vs GER?
GER results in spitting formula with gastric juice (reflux)

508

Esopageal Atresia

Esophagus ends in a blind pouch
Saliva can't make it to stomach
***No meconium because they never swallowed any amniotic fluid!
Fed with G-tube (straight into stomach)

509

Tracheoesophageal Fistula

Opening b/w trachea and esophagus
3 C's:
Coughing
Chocking
Cyanosis

-Potential for aspiration
-Pre-op, place infant on back with head and shoulders elevated to let secretions pool in lower esophagus.

-Common for moms with GI tract issues to have POLYHYDRAMIOS b/c baby never swallows amniotic fluid

510

Leukemia

-Most common form of childhood cancer
-cancer of blood forming tissue
-proliferation of immature WBC's (immunosuppressed)
--SO many WBC's no room for platelets or RBC's (thrombocytopenia and anemia)

ALL (acute lymphoid leukemia) +better prognosis
AML (acute myeloid leukemia)

511

Wilms tumor

Nephroblastoma
Found: KIDNEY or abdominal mass
-Swelling or non-tender mass on one side of abdomen
-abdominal pain, nausea/vomit

Wilms: DO NOT PALPAT ABDOMEN
-Gentle care with bathing or moving pt

512

Fontanelle Closure Times

Anterior: 7-18 months
Posterior: 1-3 months

513

Rheumatic Fever

-Inflammatory disease that occurs after an infection
-Group A B hemolitic streptococcus
Strep LOVES the heart and kidneys

Clinical manifestation: carditis!

Penicillin G or Erythromycin

514

Kawasaki Disease

Widespread inflammation of small and medium sized blood vessels.
-Coronary arteries most susceptible!

Treatment:
High dose of IV Immune G
Salicylate (ASA therapy)-aspirin
Bed rest

515

RN assessment of kids with cardiac dysfunction

-Nutritional status (failure to thrive, poor eight gain, fatigue with feeding, poor feeding habits)
-Color, chest deformities, unusual pulsations, resp effort, clubbing of fingers
-Behaviors (knee-chest position or squatting seen in some types of herat disease)
-Excessive sweating during feeding

516

CHF
Pediatric Pts

-Usually due to congenital heart defects

Early S/S:
increased pulse at rest/with slight exertion
increased RR
Scalp sweating (infants)
Fatigue
Sudden weight gain (>=1 lb/day is FLUID!)
--fluid retention, think heart problems first!

Tx:
Listen to lungs!!
Control room temp
Decrease heart workload (sit-up, rest, decrease stimuli)
Cool, humidified oxygen
Uninterrupted sleep
Feed q3hr
--20 min feedings
Digoxin
--Infants, hold if P<110, Children hold if P<70
--Normal dig level 0.8-2
Ace inhibitors- watch for cough!
Lasix

517

Patent Ductus Arteriosus

Hold between pulmonary Artery and Aorta.
Normal for fetus (O2 from placenta, not lungs). Should close after delivery.

MACHINERY LIKE MURMUR

518

Coarctation of Aorta

Narrowing of Aorta
-Difficulty for LV to pump
--Left sided HF

Dx?
Big difference in pulses and BP in UE's and LE's
Upper extremities much higher!

519

Tetrology of Fallot

PROVe

Pulmonary Stenosis
RV Hypertrophy
Overriding aorta
Ventricular Septal Defect

520

Transposition of the Great Vessels

Aorta Connected to the RA and RV
Pulmonary Artery connected to the LA and LV

2 separate sets of circulation.
Surgery required

521

Tonsillectomy

-Post op position: Side lying HOB elevated OR prone
-Don't give red or brown fluids (don't want anything confused with blood)
-What would indicate hemorrhage? Frequent swallowing
-Hemorrhage risk for 10 days

Common complains post-op?
Sore throat
Slight ear pain
Low grade temp (normal)
--spike=infection
Bad breath (old blood)

522

Intussusception

Sudden onset/episodes of pain
Currant jelly stool (maroon=blood and mucus)

523

Delegation

Designating tasks to others, but RN retains accountability

524

3 Rules of LPN Delegation

1. Only nursing care in stable situations
2. Orders not subject to change (do not delegate complex tasks)
3. Selected tasks in unstable situations

525

UAP Delegation

Non-complex tasks:
I&O
Routine Vitals (not blood, dopamine, mag sulfate, nitro)
Basic Communication
CPR (make sure doing it correctly)
Post-Mortem Care
ID Risks
Feeding pt (except stroke)

-Must teach to report back to RN on task/pt condition

526

Ulcerative Colitis

Large intestine mucosal irritation
-bloody diarrhea

-high calorie/high protein diet
-multivitamins w/ calcium
->=2 L water/day
-Journal/Avoid dietary triggers
-Avoid caffeine, alcohol, tobacco

527

Acute Pancreatitis

Symptom Relief and Prevent Complications

NPO: food increases release of pancreatic enzymes.
-Use NG tube to suction gastric secretions

Pain: IV opioids

Fluid: aggressive IV fluid replacement to prevent hypovolemic shock

Positioning: flex trunk (Semi-fowlers) to decrease pressure on abdomen OR side-lying with head elevated to 45 degrees

528

Prevent Dumping Syndrome

Multiple small meals
Low CHO diet
Do not consume fluids and food at the same time (at least 30 min apart)

529

Narcissistic Personality Disorder

Fragile/Damaged Ego

Exhibit: grandiosity, need for admiration, lack of empathy

Project: superiority, uniqueness, independence (all hides emptiness)

Why? Need to regulate/maintain fragile self-esteem

530

Anemia in Pregnancy
Based on Trimester

1: Hgb <11
2: Hgb <10.5
3: Hgb <11

531

Circumcision Home Care

-Wash hands before
-Warm water, NO soap q4h
-Petroleum Jelly at diaper changes (q4h, 3-5 days)
-Yellow exudate normal (2-3 days)
-Expect 4-6 wet diapers first 24hrs
-Bleeding size of quarter ok

About procedure:
-was a sterile procedure in hospital
-Restrained in wrapped blanket or on special board to prevent injury
-sucrose solution offered for pain

Infection: red, odor, discharge

532

Mg Toxicity
Pre-eclampsia pt

Normal (non-prego) range 1.5-2.5 mEq/L

Therapeutic Mg level in pre-eclampsia pt to prevent sz:
4-7 mEq/L

Absent/diminished DTRs (normal=2+)
Respiratory depression
<30mL/hr UO
cardiac arrest

D/C infusion

Calcium glutinate (antidote) ONLY if cardiorespiratory compromise

533

SIDS Prevention

-Less than 1 yr supine to sleep
-Firm sleep surface
-Do not share bed with caregivers
-Avoid soft objects (stuffed animals, heavy blankets, pillows). Thin tucked blanket ok
-Avoid bumper crib pads
-Smoke-free environment
-Use pacifier when placing infant to sleep (>1 month)
-Breastfeeding and keeping up infant immunizations

534

Ventricular Septal Defect

many newborns asymptomatic
acyanotic defect

HARSH SYSTOLIC MURMUR
(systole and diastole)

535

Cystic Fibrosis Features

Sinusitis
Barrel Chest
Pneumonia/bronchiectasis
Cachexia (weakening/wasting of body d/t chronic illness)
Biliary cirrhosis
Pancreatic exocrine insufficiency
CF-related diabetes
Digital clubbing
Inspissated (thicken/congeal) stools
Absent vas deferens (infertile men)

536

Alpha-Adrenergic Blockers

Function, Use, Side Effects

-ZOSIN
(terazosin, prazosin, doxazosin)
Relaxes smooth
-bladder neck, prostate gland
-peripheral vasculature

Uses:
BPH
Hypertension

Side effects:
Orthostatic hypotension, falls/syncope, dizziness, ED

Misc:
-Take at bedtime to avoid orthostatic hypotension
-Do not take with -ENAFIL meds (sildenfail, vardenafil)
---also smooth muscle relaxing

537

Radiation Poisoning

Like chemo, affects rapidly proliferating cells first:

Oral mucosa
GI tract
Bone marrow

538

Neurogenic Shock

Disruptive (vasodilatory) Shock

Affect sympathetic nervous system (SNS), not parasympathetic nervous system (PNS)

MASSIVE VASODILATION
-hypotension
-bradycardia
-warm skin, not cool/clammy

539

Opioid Use Teaching

Common side effects:
-pruritus (antihistamines)
-flushing
-hypotension (fluids, rise slowly)
-nausea (antiemetics)
-constipation (no developed tolerance)

Constipation expected long-term side effect:
defecate when urge felt, 2-3L water daily, high-fiber diet, exercise),
stool softener (Decussate)
stool stimulant (Senna)

540

Common
Selective Serotonin Retake Inhibitors
SSRI's

citalopram (Celexa)
escitalopram (Lexapro)
fluoxetine (Prozac)
fluvoxamine (Luvox)
paroxetine (Paxil)
sertraline (Zoloft)

541

Common
Monoamine Oxidase Inhibitors
MAOI's

selegiline (Emsam)
isocarboxazid (Parplan)
phenelzine (Nardil)
tranylcypromine (Parnate)

542

Candida Albicans

Fungal infection
oral candidiasis (thus)

White patches on oral mucosa, palate, tongue
Non-removable and tend to bleed when touched

543

Atrial Fibrillation Treatment Goals

Ventricular HR <100
Diltiazem (Ca Blocker)
Metoprolol
Digoxin

If you want to change rhythm to NSR:
amiodarone or ibutilide

544

Clonidine Patch

-change and rotate sites every 7 days
-dry hairless area on upper chest/arm
-no shaving before patch (razor burn)
-discard by folding sticky sides together
-1 patch at a time
-DO NOT stop using abruptly

545

Proof of repercussion after STEMI

Return of ST segment to baseline

-thrombolytic therapy can stop infarction process in STEMI
-given first 12 hrs of symptom onset

546

Infant Increased ICP S/S

fever
vomit
high-pitched cry
irritability

bulging fontanelle
"sunset eyes"
Prominent scalp veins
Increased head circumference

Potential bacterial meningitis

547

Dislodged Tracheostomy Tube
RN Action

-If mature (>7 days), insert new trach with obturator.

-If unable to: cover w/ sterile occlusive dressing (3 sides)
-ventilate w/ bag-valve mask over nose/mouth

548

IV Potassium Chloride
(KCl)

Central Venous Access Device (PICC, CVC):
Concentration: 20-40 mEq/100mL
Max Rate: 40 mEq/hr

Peripheral:
Concentration: 10 mEq/100mL

-KCl irritates vein
-May slow infusion rate to decrease discomfort.

549

Transfusion Reaction
RN Interventions

1. D/C immediately
2. Maintain IV access w/ NS and new tubing (prevent hypotension and vascular collapse)
3. Notify HCP and blood bank
4. Monitor Vitals
5. Recheck labels, #'s, blood type
6. Treat clients Sx based on HCP Rx
7. Collect blood/urine specimens to evaluate for hemolysis
8. Return blood/tubing set to blood bank
9. Documentation/paperwork

550

Autonomic dysreflexia

aka. Hyperreflexia
Spinal cord injuries >=T6
Exaggerated sympathetic nervous system response
HYPERTENSIVE EMERGENCY (uncontrolled HTN)
-Can lead to stroke or MI

Manifestations:
-acute onset of throbbing headache
-nausea, and blurred vision
-hypertension and bradycardia
-diaphoresis and skin flushing above the level of the injury

Triggers:
Bladder distension
Rectum distension
Pressure Ulcers

Treatment:
Check BP, Check bladder (cath), digital rectal exam, remove constrict clothing

551

Need for Cerebral Spine Stabilization

NSAIDS

N=neuro exam (numbness, decreased strength)

S=significant traumatic mechanism of injury

A=alertness

I=intoxication (decreased pain awareness)

D=distracting injury (not paying attention to spine)

S= spinal exam
(midline or point tenderness spine/neck)

552

Diabetic client wants to fast for religious reasons.
RN Action?

Assess for risk of adverse events!

-Clinical stability (comorbidities)
-glycemic control (hyper/hypo-glycemic episodes, medication regimen, knowledge, ability to self-monitor BG during fast)

553

Acute Pericarditis

Inflamed layers of pericardium rubbing against heart causing pain.
-ST Elevation in ALL EKG leads! (MI localized to leads being effected)
-CARDIAC TAMPONADE LETHAL COMPLICATION

-Worse with deep breathing/supine
-sit up and lean forward (fowlers or high fowlers)

554

Cholecystitis

Gallbladder inflammation

-Vomiting? NPO!
If in any major pain, NPO to decrease gall bladder stimulation.
-Low-grade fever, chills, nausea, vomit, anorexia
-RUQ pain (Murphy's sign) radiating to R shoulder or scapula
-Then deal with pain, fluid imbalance, and gastric decompression (NG Tube)
-FATTY FOODS 1-3 hrs pre-onset

Interventions:
Sims position
Deep breathing
Ambulation
Analgesics

555

Paralytic ileus

Temporary paralysis of portion of bowel.
Affects peristalsis and bowel motility

S/S: abdominal discomfort, distention, nausea/vomiting.

Risk Factors:
Abdominal surgery, perioperative meds (opioids, anesthesia, analgesics), immobility (stroke)

Treatment:
-NPO
-NG tube wall suction to decompress stomach
-F/E replacement to correct losses from NG suction
-Antiemetics (ondansetron, promethazine)

556

Epinephrine and Norepinephrine
vessel action

Adrenal Medulla
Fight/Flight Hormones

Acts directly on smooth muscles of blood vessels to CONSTRICT them

Norepi medication is a vasoconstrictor and vesicant that can cause tissue necrosis

557

What to avoid during therapeutic communication

"WHY" questions.
Viewed as critical, judgmental, and intrusive.

Voicing doubt ok.

558

Herbal supplements that increase risk for bleeding

-Gingko biloba (memory, claudation)
-Garlic
-Ginseng (improved mental performance)
-Ginger
-Feverfew

559

Intrapartum fetal HR monitoring mneumonic

VEAL CHOP
Variable-Cord compression

Early- Head compression

Accelerations- OK

Late- Placental insufficiency

560

Rotavirus

Contagious Virus
Leading cause of diarrhea in kids <5.
-Dehydration major risk!

Fecal-oral

Vaccination for kids less than 8 months old.

Contact w/ food, toys, diaper, and hands

*Hand washing
8

561

Heatstroke

-Temp >104F
-Hot, dry skin
-Hemodynamic instability (tachycardia, hypotension)
-AMS/neuro symptoms (confusion, lethargy, coma

Risk for permanent near injury or death directly related to duration.

ABC's and rapid cooling:
-cool water immersion
-cool IV fluids
Antipyretics INEFFECTIVE b/c unrelated to inflammatory process.

562

IV Potassium Chloride
KCl

Concentration: 40 mEq/L

Infusion Rate Max:
Central Line- 40 mEq/hr
Peripheral Line- 10 mEq/hr

Pain at peripheral site, slow IV infusion rate

563

Vitamin K Food

Do not eat with warfarin!

Greens!
green leafy veggies, cauliflower, broccoli, cabbage, lettuce, spinach, brussel sprouts

564

Do not eat with warfarin...

High vitamin K foods
Green tea, grapefruit juice, cranberry juice

565

Frostbite Treatment

-Do NOT massage/rub/squeeze
-Immerse in warm water (98.6-102.2)
-analgesia
-remove clothing/jewelry
-NO heavy blankets/clothing to prevent tissue sloughing
-While thawing, area may become edematous (ELEVATE) and blister
-Keep wounds open immediately after a water bath and allow them to dry before applying loose, non adherent, sterile dressings
-Monitor s/s compartment syndrome

566

Post-up naloxone

RN Action after:
1 dose given, 1 hr later decreased respiratory rate and low arousability

-Administer oxygen
-Assess respiratory rate
-Notify HCP
-Prepare 2nd dose!

Naloxone has shorter half life than most opioids. Wears off 1-2 hours.

567

Clozapine

Use?
Adverse effects?

-Atypical antipsychotic
-Treatment-resistant Schizophrenia
-AGRANULOCYTOSIS!

Monitor WBC (>3,500) count and ANC (>2000)
*Monitor WBC and ANC weekly*

Metabolic Syndrome
-weight gain
-hyperglycemia
-dyslipidema

Seizures

568

Glucocorticoid side effects

*Prednisone
*Methylprednisolone
*Dexamethasone

Side effects:
-increase in blood sugar
-fluid retention/increased hypertension
-stop suddenly can lead to adrenal crisis

569

1 oz converted to mL

1oz = 30mL

570

Caput succedaneum

CS=crosses suture

Edema/hematoma above periosteum that CROSSES suture lines

feels "spongy" and closes suture

*Resolves within first week

Expected finding

571

Cephalohematoma

Subperiosteal bleed that DOES NOT CROSS suture lines

Expected finding

572

Crutches Safety

-Clutter free (rugs)
-Look forward
-Use small backpack/bag to hold items to keep hands free
-Rubber/non-skid soled slippers/shoes
-Keep rubber tips dry

573

Measuring/Assessing JVD

-Bed at 30-44 degrees (semi-fowlers)
-Pulsation of neck veins

574

Referring Syndrome

Declines in PPM
Phosphorous (2.4-4.4)
Potassium (3.5-5)
Magnesium (1.5-2.5)

Other:
fluid overload, Na retention, hyperglycemia, thiamine deficiency

Actions to prevent refeeding syndrome include the following:

Obtaining baseline electrolytes
Initiating nutrition support cautiously with hypocaloric feedings
Closely monitoring electrolytes
Increasing caloric intake gradually

575

Splenectomy lifelong risk for...

RAPID SEPSIS!
Even low-grade fever should be taken seriously with these clients.

A lot of vaccines:
pneumococcus, meningococcus, haemophilus influenzae type B

576

Cellulitis

Common skin bacterial infection

IV antibiotics in clients with DM

577

RN Plan of Care for
Pertussis Infection

-Droplet precautions
-Monitor signs airway obstruction
-Small amounts of fluid frequently
-Oral antibiotics
-Supportive measures (humidified oxygen)
-cough >2 wks
->1 wk paroxysms of cough, inspiratory whooping sound, and posttussive vomiting

578

Acute appendicitis

Appendix

-ABDOMINAL pain (belly button to RLQ)
-POINT of McBurney's (most pain, b/w belly button and hip bone)
-POOR appetite
-ELEVATED temp
-NAUSEA/vomiting
-DESIRE to be in fetal position/relieve pain
-INCREASED WBC, inability to pass gas or have BM
-rebound tenderness RLQ

-Surgery required in first 24 hrs

579

Vaso-occlusive Crisis

Pain crisis in Sickle Cell Disease

Elevated reticulocytes
Elevated bilirubin
Anemia

NOT RELATED: rbc's, high k.

580

Psoriasis
Look
Management

Chronic autoimmune disease-rapid turnover of epidermal cells.
-silver plaques on reddened skin
-NO CURE

Manage:
-avoid triggers (stress, trauma, infection)
-topical therapy (corticosteroids, moisturizers)
-phototherapy/sunlight
-systemic medications, cytotoxic (methotrexate) and biologic (infliximab) agents

581

Post-op Chest Tube
Drainage

-Excessive drainage (>100 mL/hr)
-Air/fluid in chest (diminished breath sounds)
-pain
-infection at drainage site
-Excess drainage of frank red blood = hemorrhage must be managed immediately
-Assess every hr for first 8 hrs
-Then every 8 hours until removed

582

Cyclobenzaprine

Flexural
Common centrally acting muscle relaxant:

For muscle spasticity, muscle rigidity, acute/chronic muscle pain/injury.

Metabolized by LIVER.
Toxicity with liver disease (hepatitis) and increased CNS depression

583

Cognitive Behavioral Therapy

Maladaptive reactions to stress, anxiety, and conflict:

CBT has 5 basic components:
-Education about disorder
-Self-observation and monitoring -anxiety, identify triggers, and assess the severity
-Physical control strategies – deep breathing and muscle relaxation exercises
-Cognitive restructuring – learning new ways to reframe thinking patterns
-Behavioral strategies – focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events

NOT: interpersonal psychotherapy, NOT psychodynamic therapy

584

Calcium Channel Blockers

Very Nice Drugs
Verapamil, Nifedipine, Diltiazem

Blocks Ca access to cells causing:
Decreased heart contractility/rate
Decreased demand for oxygen
Decreases PVR

Uses: angina, HTN, dysrhythmias (verapamil, dilt)

585

Dental avulsion

Tooth separated from mouth.
If permanent tooth- DENTAL EMERGENCY!

Re-implantation in 15 min reestablishes blood supply. Tooth might survive.
Can put tooth in:
cold milk, sterile saline, Hanks balanced salt solution.

NOT hypotonic solution!

586

Hypoglycemia S/S

BG <70
Epi released!
Trembling/Shakiness
Palpitations
Anxiety/arousal
Restlessness
Diaphoresis/pallor

Prolonged Hypoglycemia:
neuro symptoms!
confusion
seizures
coma

587

Receptive Aphasia
Intervention

Impairment or loss of language comprehension (speech, reading)

-Ask short, simple, "yes" "no" questions
-Use gestures or pictures to demonstrate activities
-Remain patient and calm, allowing pt to understand each instruction
-eye contact

do NOT:
raise voice. Hearing isn't the issue

588

Peptic Ulcer Disease Treatment
*Types of Ulcers

"Triple Drug Therapy" 14 days
Amoxicillin, Clarithromycin, Omeprazole
-Avoid triggers
-Stop smoking, drinking

Duodenal Ulcers: Pain 2-3 hrs post meals
Food might decrease pain

Gastric Ulcers: aPain 30 min- 1 hr after meals
Eating increases pain

Stress ulcers- Cushing's ulcers (brain injury), Curling's Ulcer (extensive burns)

589

Emergency Drugs to LEAN on

Lidocaine (V-arrhythmias, MI's)
Epinephrine
Atropine (treats brady)
Narcan (opioid reversal)

590

IDEA for slow HR and BP

Isoproternol- relaxes BV and increases cardiac pump efficiency
Dopamine- Increases pump strength
Epinephrine- constricts peripheral BVs to shunt blood to heart and brain
Atropine- anticholinergic- treats symptomatic brady

591

ABCDE for atrial arrhythmias

Anticoagulants
Beta Blockers (slow HR)
Ca Channel Blockers (slow HR, contractility, smooth muscle relaxation)
Digoxin (stronger HR)
Electrocardioversion

592

Anticholinergic drugs

Cause decrease in parasympathetic effects!
S/S-Same as sympathetic fight/flight

Decreased smooth muscle spasms
Decreased digestion
Pupil dilation
Increased secretions
Increased HR
Airway relax

Atropine, Ipratropium, Benztropine, Scopolamine, Oxybutynin
Uses: AV blocks, mydriasis for retinal exams, Increased HR for symptomatic bradycardia

593

Death Rattle

Actively dying
Unable to manage airway/clear secretions

Give anticholinergics to dry secretions!
Atropine drops
Scopolamine patch

594

Small Bowel Obstruction
S/S

Treatment

-rapid onset nausea/vomit
-colicky, intermittent abd pain
-distension

Treatment:
NPO
NG tube
IV fluids
Pain treatment

595

Large Bowel Obstruction
S/S

-gradual onset of symptoms
-cramping/abd pain
-distension
-ABSOLUTE constipation
-lack of flatus

596

Meds Pregos CANNOT have

Ace inhibitors
doxycycline
isotretinoin (accutane)

NSAIDS (aspirin, ibuprofen-Motrin/Advil)
Thalidomide

597

Fondaparinux

Unfractioned heparin

Do not give until >6 hrs post op
-same rule for LMW heparin

598

Sjogren's Syndrome

-Auto immune disorder
-WBC's attack moisture-producing exocrine glands

-Salivary gland decrease: Xerostomia (dry mouth)

-Lacrimal gland decrease: Xerophthalmia (dry eyes)

Dry skin (itchiness, rash), throat/bronchi (dry cough)

***Avoid decongestants! Further dryness
*Avoid oral irritants (coffee, alcohol, nicotine, acidic drinks)

Treatment:
eye drops, SF candy, lubricant, frequent dental exams, lukewarm showers/mild soap, avoid decongestants (oxymetazoline, phenylephrine, pseudo ephedrine)

599

Dislodged CVC
RN action

-Oxygen non-rebreather
-Occlusive dressing
-Monitor VS/Resp effort
-Notify HCP
-Left Lateral Trendelenburg

600

Inserting NG Tube for gastric decompression

1. Hand hygiene and apply clean gloves (not sterile)
2. Pt in high Fowler's position
3.Assess nares and oral cavity and select naris
4. Measure (nose, ear, typhoid) and mark the tube
5.Curve 4-6" tube around index finger and release
6.Lubricate end of tube with water-soluble jelly
7. Instruct client to extend neck back slightly
8. Gently insert tube just past nasopharynx, aiming tip downward
9. Rotate tube slightly if resistance is met, allowing rest periods for client
10. Continue insertion until just above oropharynx
11. Ask client to flex head forward and swallow small sips of water (or dry if NPO)
12. Advance tube to marked point
13. Verify tube placement and anchor - use agency policy and procedure to verify placement by anchoring tube in place and obtaining an abdominal x-ray.

-Aspirating gastric contents and testing the pH may also give an indication of placement (pH should be 5.5 or below).
-Auscultation of inserted air is acceptable for confirming tube placement initially, but is not definitive as it is not an evidence-based method.
-Nothing may be administered through the tube until x-ray confirmation is obtained, or this may cause aspiration.

601

Gastric Lavage

-Use large-bore (36-42 french) orogastric tube
-Removes ingested toxins/irrigates stomach
-Intubation/suction supplies ready in case of emergency
-pt on their side or with head of bed elevated
-initiate within 1 hr of OD

Activated charcoal admin is standard treatment for OD, but ineffective for lithium, iron, alcohol

602

PTSD communication

They believe they are responsible/to blame. Will experience guilt/shame.

Convey that what happened was not their fault.

603

Disulfiram

Antabuse
Aversion therapy-alcohol abstinence

If alcohol consumed, pt may experience headache, intense nausea/vomit, flushed skin, sweating, dyspnea, confusion, tacky, hypotension).

Large amount can be FATAL

Hidden alcohols in:
-liquid cold/cough meds
-aftershave, lotions, colognes, mouthwashes
-foods such as sauces, vinegars, flavor extracts

Abstain from alcohol for 2 weeks after last dose b/c run could still occur

Wear med bracelet to let others know you're on disulfiram therapy

604

Cryptorchidism

undescended testicle

-If at birth, not concerning. Most descend spontaneously by age 6 months

605

Concerning fetal abnormalities at birth

Cranial nerve abnormalities.
Ex. ptosis (drooping of eyelid below level of pupil)

Normal: rales (crackles) for a few hrs after birth.
Dull percussion over bladder (full bladder)

606

HELLP Syndrome

Severe form of preeclampsia:

Hemolysis
Elevated Liver enzymes
Low Platelet count

Presentation:
(sometimes non-specific)
RUQ pain
nausea
vomit
malaise

If not treated immediately could lead to placental abruption, stroke, and death

607

Cystitis

-Most commonly acquired UTI (e.coli)
-Lower UT
-Bladder (mucosa) inflammation!

S/S:
-burning urination (dysuria)
-urinary frequency
-urinary urgency
-hematuria
-suprapubic discomfort

608

Pyelonephritis

Kidney infection (e.coli)!
Can ascend from bladder.
-nausea
-vomit
-FEVER WITH CHILLS
-FLANK PAIN EXTENDING TOWARDS UMBILICUS
(costovertebral angle tenderness)

609

Huff coughing
Why?
How?

COPD
-need to learn to expectorate mucus without high-pressure coughs (incapable)

1. Position upright
2. Inhale through the nose using abdominal breathing and prolong the exhalation through pursed lips for 3 breaths – deflates excess air from lungs
3. Hold breath for 2–3 seconds following an inhalation, keeping the throat open
4. Deeply inhale and, while leaning forward, force the breath out gently using the abdominal muscles while making a "ha" sound (huff cough); repeat 2 more times (eg, "ha, ha, ha") – keeps airways open while moving secretions up and out of the lungs.
5. Inhale deeply using abdominal breathing and give one forced huff cough – the last, increased force ("ha") usually results in mucus being expectorated from the larger airways.

610

Transplant patients highly...

IMMUNOSUPPRESSED!
On strong immunosuppressant meds.
Infection can be rapidly progressing and be FATAL.
Low grade feel is a priority.

611

Thiazolidinediones

rosiGLITAZONE
pioGLITAZONE
*Treat type 2 diabetes*
increase insulin sensitivity

-Can worsen heart failure by causing fluid retention
-Risk:bladder cancer
-risk: heart events (MI)

-low risk for hypoglycemia

NO retinopathy risk related to the med.

612

Coronary Arteriogram

Angiogram

-invasive diagnostic study coronary arteries, heart chambers, function

-NPO 6-12 hrs before
-warm and flushed when dye injected
-may have to lie flat for several hours to ensure hemostatis in artery that was cannulated for procedure.
-NOT general anesthesia
-can usually go home that day

613

Neonatal heel stick

-medial or lateral side of outer aspect of heel
-warm heel for several minutes with warm towel
-sucrose and nonnutritive sucking
-cleanse with alcohol
-automatic lancet

Acceptable alternate method: venipuncture (draw blood from vein)
-less painful
-fewer punctures for more larger sample

614

Fecal incontinence
Types

aka. encopresis, soiling
>4 years old

Functional: retentive
-constipated for days, painful stool, repeat cycle (think of parents that only feed their kids candy)
-reward system to encourage child's involvement in treatment

Psychosocial (non retentive)- cannot control feces

615

Adverse events

Error types

-Injuries caused by medical management, NOT client's underlying condition.

Error types:
-diagnostic
-treatment
-preventive
-other (failure to communicate, equipment failure system failure

616

Cerebral aneurysms

Asymptomatic bless they rupture
"silent killers"

"The worst headache of my life"

617

Long bone fractures

Femur
Humorous
Tibia

POTENTIAL FAT EMBOLUS!
Travel to lungs, skin, and brain
AMS= blocked blood vessels in brain!
Lungs=respiratory distress

Hallmark sign: PETECHIA-pin sized red/purple spots
small vessels clotting.
Chest, axillae, soft palate

618

Hyperkalemia Med Admin

If peaked T waves:
1) calcium glutinate
2) insulin/dextrose

If no peaked T waves, start insulin/dextrose

619

Levetiracetam

Keppra
Anticonvulsant for seizure disorders

Depresses CNS:
drowsiness, somnolence, fatigue AS CLIENTS ADJUST to meds
-Typically improves in 4-6 wks

Risks needing immediate attention:
-increased anxiety, depression, SI
-Stevens-Johnson syndrome (blistering skin)

620

Driving for patients with seizures

Avoid driving or operating heavy machinery until they have permission from their HCP

Usually requirements from department of transportation (sz free for certain period of time)

621

Stevens-Johnson syndrome

Rare, but life-threatening blistering reaction of skin.
MEDICAL EMERGENCY!

1. flu-like symptoms
2. painful rash
3. blistering

Other:
fever, malaise, coughing, eye redness, itching, mouth ulcer, sensitivity to light, sore throat, selling, peeling, rash of purplish or red spots

622

Acanthosis nigricans

-Skin condition
-Usually obesity and diabetes

Velvet-like patches of darkened, thick skin

Usually around back of neck, groin, and armpits

623

Respiratory Depression r/t Opioid use for Analgesia
RISK FACTORS

-the elderly
-underlying pulmonary disease
-hx of snoring (w or w/o apnea)
-obesity
-smoking (>20-pack-year hx)
-the opiate naive
-24 hrs post-op

624

When to see HCP for diarrhea

>48 hrs
OR
accompanied by fever or bloody stools

Diarrhea usually self-limiting (48hrs)

625

aPTT time

30-40 seconds

If on anticoag therapy:
46-70 seconds

626

LPN Scope

-Monitoring RN findings
-Reinforce education
-Routine sterile procedures (eg. catheterization)
-Most med admin
-Ostomy care
-Tube potency and enteral feeding
-focused assessments
-collection of specimens
-Stable clients

-measure stockings or devices/choose appropriate device

627

Medically emancipated minor

Minors can provide own consent.

-Emergency care
-STI
-Substance abuse
-Prego care
-Contraception


Regular Emancipated minor:
homeless, parent, married, military, financially independent, HS grad

628

Reaction Formation

Behaving in a manner or expressing a feeling opposite of ones true feelings

Ex. A parent who is resentful of an "unplanned" child become overprotective

629

Sublimation

Transforming unacceptable thoughts or needs into acceptable actions.

Ex. Aggressive person becomes star boxer.

630

Drugs to lower Ventricular Rate

DILTiazem
MetroprOLOL
DIGoxin

631

Target BP and HbA1c for Diabetic Pts

<140/90
<7%

632

Expected findings in pneumonia

fever
chills
fatigue
crackles
sputum production

633

DVT Risk Factors

-Trauma
-Major Surgery
-Prolonged immobilization
-Oral contraceptives
-Underlying malignancy
-Smoking
-Old age
-Obesity and varicose veins
-Myeloproliferative disorders (increased blood viscosity)

634

Retinoblastoma

Retinal Tumor
-usually dx kids <2

White "glow" of one or both pupil(s) (leukocornia)
-white instead of red in photos

Strabismus 2nd most common sign
-misalignment of the eyes

635

IV Opioid Analgesics

Admin and Side Effects

Hydromorphone/Morphine

-SLOWLY Over 2-3 minutes

Sedation
Resp depression
Hypotension
Constipation

REASSESS during opioid's peak effect!
15-30 min for hydromorphone

636

Sedation Level Scale

S-sleepy
1- awake, alert
2-slightly drowsy, easy to arouse
3- falls asleep during conversation (unacceptable)
4-somnolent (stop sedation, maybe use naloxone)

637

Iron Supplement

NO MILK

Better on empty stomach
Vitamin C increases absorption (citrus fruits/juices)

638

Warning signs of cancer

CAUTION
-Change in bowel or bladder habits
-A sore that does not heal
-Unusual bleeding/discharge
-Thickening or lump
-Ingestion or difficulty swallowing
-Obvious change in wart/mole
-Nagging cough/hoarseness

639

Acceptable Residual Urine

<100mL

Report amounts >100mL to HCP

640

Parkinson's Disease

-Trembling of extremities
-Resting tremor
-Stooped posture
-Rigidity
-Masked facial expression
-Forward tilt of trunk
-Reduced arm swinging
-Slightly flexed hips/knees
-Shuffling, short gait

641

Serotonin Syndrome

*Potentially lethal
*OD Antidepressants

-Mental status change (anxiety, agitation, disorientation)
-Autonomic dysregulation (hyperthermia, diaphoresis, tachy/htn, mydriasis)
-Neuromuscular hyperactivity (tremor, muscle rigidity, clonus, hyperfreflexia, diarrhea, hyperactive bowel)

642

Peripheral Artery Disease

Risk Factors:
Smoking
DM
Hyperlipidemia
Smoking

Pain in LE's with movement/exercise d/t ischemia
At rest, might experience burning, aching, numbness

643

Saw palmetto

Natural Herb:
BPH

644

Hawthorn extract

Natural Herb:
Heart failure

approved in Germany

645

Major depressive disorder
2 key clinical features

aka: unipolar depression

1. Depressed Mood
2. Loss of interest or pleasure (anhedonia)

1 sx above for >=2 weeks

Other: SIGECAPS
Sleep (up/down)
Interest deficit (anhedonia)
Guilt
Energy deficit
Concentration deficit
Appetite (up/down)
Psychomotor retardation/agitation
Suicidality

646

Testicular torsion

Emergency Condition
Stopped blood flow to testis (scrotum), hehe :D

-Testicle rotates/twists the spermatic cord
-swelling/severe pain
-testicular ischemia and necrosis
-Small treatment window! 4-6 hrs
--use ultrasound to dx
-Emergency surgery

Potential testicle death!

647

Severe asthma exacerbation characteristics and treatment

-Tachycardia >120
-Tachypnea >30
-O2 Sat <90RA
-Accessory muscle use
-Peak expiatory flow
-<40% predicted or best (<150 L/min)

1. Oxygen
2. High-dose inhaled short acting beta agonist (ALBUTEROL) and anticholinergic agent (IPRATROPIUM) neb treatment q20min
3. Systemic corticosteroids (Solu-Medrol)

648

Wound Culture procedure

1. Hand hygiene, gloves, remove old dressing, d/c gloves

2. hands again, STERILE gloves, assess wound.
Cleanse with normal saline. Remove gloves

3. hands again, CLEAN gloves, swab from center to outer margin.
AVOID contact with skin at wound edge.

4. swab in STERILE specimen container.

5. Apply topical med, BACITRACIN, after culture. Apply new dressing

6. remove gloves, hand hygiene, label specimen, document

649

Gout

hyperuricemia
Urate crystal deposits (aka, TOPHI) in joints

650

Normal ICP

ICP while doing RN interventions on pt with brain injury

Normal: 7-15 mmHg

Max for working on pt with brain injury: 25mmHg
Should return to baseline within a few minutes

651

RN interventions to control ICP

-HOB 30 degrees, maintain neutral alignment
-Stool softeners
-manage pain well
-calm environment
-adequate O2
-Hyperventilate and pre oxygenate before suction
-avoid clustering care

652

Hypoxic client:
Post op care after general anesthesia

Obese person probably has obstruction (use of accessory muscles, snoring, decreased O2, cyanosis)


Head tilt and chin lift to open occluded airway

653

RN interventions for a newborn immediately after delivery

1. Standard precautions (gloves)
2. Maintain clear airway
*pharynx first, nares second*
3. Thermoregulation (97.5-99)
4. IM vitamin K injection in vastus laterals within 6 hrs (mid anterior lateral thigh)
7. Ophthalmic ointment for gonorrhoeae legally required (within 1 hr)
8. Initial bath! Remove blood, bodily fluids, or meconium.
Leave vernix caseosa (waxy white coating)

654

Suspected urinary retention

Opioids, anticholinergic meds, tricyclic antidepressants

Increase bladder sphincter tone and/or relax bladder muscle

RN intervention:
palpate suprapubic area

655

Shock Continuum: Stages of Shock

I. Initial
-inadequate O2 to supply the demand.
-Anaerobic metabolism.
-No recognizable S/S

II. Compensatory
ex. urinary retention to maintain fluid volume.
-Tachycardia to maintain cardiac output and O2 demand.

III. Progressive
-Failure of compensatory
-cold and clammy skin

IV. Irreversible

656

Normal urine output

0.5-1 mL/kg/hr
OR
>30mL/hr

657

ALS

Amyotrophic Lateral Sclerosis
-progressive loss of motor neurons in brainstem and spinal cord

Client Care Focus:
Respiratory function, adequate nutrition, quality of life
*Dysarthria=worsening ability to speak. May also have dysphagia and rest distress

No cure
Death usually in 5 years

658

External Fixation

Stabilizes bone with inserted metal pins through skin into bone.
Metal pins attached to rod outside of skin.

S/S infection:
low-grade fever
drainage
pain
redness
swelling
***immediate treatment

Could lead to osteomyelitis!!!

659

Chronic subdural hematoma

-Bleeding into subdural space.
-Can occur several weeks to months following a mild head trauma

-Elderly on anticoags are at high risk.
-Elderly also at risk because of falls.

Manifestations:
headache
gait disturbance
memory loss
decreased LOC

*Investigate Immediately!*

660

Expected findings in neonate 1-3 hrs post-delivery

-Blood glucose above 40, but below 70.
(normal 70-100)

-Resp rate 30-60
Might be sightly irregular, diaphragmatic, and shallow

-Milia (white papule) on nose and chin. Resolve without treatment within several weeks



Abnormal:
-holosystolic murmur=VSD

661

Down Syndrome

Trisomy 21

single transverse crease across palm

small and low-set ears

flat nose bridge

protruding tongue

hypotonia

662

Total joint replacement surgery contraindications

Recent/current infection
ex. burning on urination

Report to HCP immediately

663

Cirrhotic Liver
Blood Test Values

-Elevated bilirubin (jaundice)

-Elevated PT INR, aPTT
(Liver makes coagulation factors)

-Ammonia (usually converted to urea in liver and excreted by kidney).
-increases and crosses blood-brain barrier leading to *hepatic encephalopathy*

-Decreased albumin
Liver unable to synthesize protein (albumin)

-Decreased sodium
With 3rd spacing r/t low albumin, kidney tries to conserve sodium and water. Na gets diluted!

664

Endotracheal tube suctioning

1. gloves
2. suction oropharynx/oral care
3. wall suction <120 mmHg
4. hyper oxygenate
5. advance cath until resistance met
6. remove with intermittent suction <10 seconds
7. evaluate tolerance. Repeat 1-2 times
8. resume oxygenation/vent settings

665

Risk factors and symptoms for pelvic inflammatory disease (PID)

*leading cause of ectopic pregnancy and infertility*

-Multiple sexual partners
-Hx of chlamydia or gonorrhea
-Hx of PID
-Partner with STI
-Lack of consistent barrier contraception use (no condoms)
-Age 15-25

Symptoms:
-pelvic/lower and pain -menstrual irregularities
-increased menstrual cramps
-painful intercourse
-fever
-abnormal vag discharge

666

Prevent Post-Op Pneumonia

-Adequate pain control
-Ambulate within 8 hrs if possible
-Coughing with splinting q1hr
-Deep breathing/incentive spirometer every hr
-Fowler's position (45-60 degrees)
-Turn/reposition q2hr
-Swab mouth with chlorhexidine swabs q12hr
-hand hygiene!

667

TB associated S/S

Tb in any location:
-Night sweats
-Low grade fever
-Anorexia and Weight loss
-Fatigue

Pulmonary TB:
-cough
-purulent or blood-tinged sputum
-SOB

668

Splenic sequestration crisis

Finding: rapidly enlarging spleen

Life Threatening!
Leads to hypovolemia (hypotensive) shock.

Occurs when a large number of "sickled" cells get trapped in spleen causing splenomegaly.

669

Vegan Diet Complications

Low intake of Vitamin B12 (cobalamin)
-only in animal proteins

At risk for megaloblastic anemia and neurological manifestations

Cobalamin deficiency affects entire nervous system from peripheral nerves to spinal cord and brain.

"hands and feet get tingly sensation"

670

Progestin-only Pills
(POPs)

-oral contraction
-thicken cervical mucus (hinders sperm motility)
-thins endometrium (hinders implantation)

-Same time everyday
->=3 hrs late, barrier method advised until pill correctly taken for 2 days
-additional POP taken if diarrhea or vomit occurs within 3 hrs of last dose
-No inactive pills in POP pack. No break from hormone to menstruate
-breakthrough bleeding commonly reported
-Low cardiovascular risk profile, so lower risk for clots

671

Therapeutic hypothermia

-Cardiac arrest
-Comatose
OR
-Do not follow commands after resuscitation

-Neurologic injury most common cause of death in V-fib and pulseless V-tach.
**this improves neurologic outcomes and decreases mortality

-induce within 6 hrs of arrest
-maintain for 24 hrs
-89.6-93.2 degrees
-cooling blankets; ice placed in groin, axillae, sides of neck; cold IV fluids

672

Carboxyhemoglobin Level

Carbon monoxide

Normal: <5%

Smokers: <10%

Pulse oximeter can't detect difference between O2 and CO.

CO poisoning:
headache, dizzy, fatigue, nausea, dyspnea

673

Colorectal Cancer S/S

-blood in stool
-abd discomfort
-anemia d/t intestinal bleeding
-change in bowel habits
-unexplained weight loss

>50 routine colorectal cancer screening

674

Seizure manifestation Phases

1. prodromal phase: warning signs
2. aural phase: visual/sensory changes
3. Ictal phase: SEIZURE!
4. Postictal pose: confusion/recovery

675

Erratic plethysmograph waveform.
First action?

Check/Asses the patient's O2/perfusion status and assess for motion artifact.

676

Bacterial meningitis care

-Droplet isolation (surgical mask, private room, pt masked during transport)
-Reduced stimulus (quiet, dimly lit, coo temp)
-HOB 10-30 degrees
-Seizure precautions (padded bed rails, O2 and suction at bedside)

677

Pincer Grasp Age

-Thumb and forefinger movement
**develops at 8-10 months**

Can pick up small finger foods

678

When to introduce allergenic foods to babies

4-6 months of age

Examples?
Eggs, fish, peanut products

679

Agoraphobia

fear and anxiety about being in (or anticipating) certain situations or physical spaces.

Examples:
-Outside the home alone
-In a crowd or standing in line
-Traveling in a bus, train, car, ship, or airplane
-On a bridge or in a tunnel
-Open spaces (eg, parking lots, marketplaces)
-Enclosed spaces (eg, theaters, concert halls, stores)

680

Renal Calculi Pain

Excruciating, sharp, and stabbing

Unable to find comfortable position

Pain radiates down to groin as stone travels

681

ATK amputation post op

Above-the-knee amputation

-Residual limb should not be elevated!
*Figure eight compression bandage*
-Prone 30 min 3-4x/day
-abductor pillow
-no bending at hip more than 90 degrees
-no crossing legs

682

When to hold insulin

Possibly when client is NPO

Glucose below 70 mg/dL

683

Alzheimer's Safety Mods

-Arrange furniture to allow for free movement

-Frequently used items in easy reach

-Lock on stairwells

-Label doors to bathroom

-Provide nightlight to prevent falls, aid in orientation, and decrease illusions

684

Vaginal hematoma
Cause
S/S

-formed when trauma to perineum (forceps, vacuum, episiotomy)

-persistent, severe vaginal pain

-feeling of fullness

-Uterine funds firm/midline

-Unchanged vaginal bleeding

685

Post-mortem care

-Family participation ok
-maintain standard/isolation precautions until TOD
-Remove tubes/dressings (unless autopsy or organ harvest pending)
-Straighten and wash the body
-Change the linens
-Leave dentures in place or replace them
-Fold towel under chin to keep jaw closed
-Pad under perineum (leaking stool/urine)
-Place a pillow under the head (prevent blood from pooling and discoloring)
-Remove equipment and soiled linens from the room
-Give client's belongings to a family member or sent with the body

686

Don PPE Order

Hand hygiene

Gown

Mask or Respirator

Goggles or Face Shield

Gloves

687

Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Frontal: personality and behavior

Parietal: somatic and sensory input

Occipital: Vision

Temporal: Auditory input and past experiences

688

Normal aPTT

Anticoagulant Therapeutic aPTT

25-35 seconds

1.5-2x greater if on heparin

46-70 seconds